Top 5 Radiology Pet Peeves

I don't typically write posts just to rant or complain... there's usually some kind of important issue if I do that influences patient care or the overall status of our profession.  However, the last month or so has provided me with a list of pet peeves that seem to be growing and growing like tumor in my brain.  I hope I don't "bring you down" or "send off bad vibes" with this post as my Step-Father's circa 1969 vocabulary (still in use) might suggest, and please feel free to reply with your own pet peeves... it can be quite therapeutic to vent these things, and you never know... we may be able to come up with some solutions to these issues together.


Pet Peeve #5 - Patients wanting to know your opinion about their x-rays:

I'm not talking about patients who are unaware that it is illegal for you to give your opinion.  I'm talking about the ones who, after you explain that you cannot give your opinion because you are not a Physician and you could lose your license for doing so, persist saying things like "come on... I know that you know what you're looking at!" Simply wanting a quick result of an x-ray isn't enough to call it a pet peeve... it's the pursuit of your opinion beyond explanation of legality that drives me batty.  I have had patients argue with me for 10-15 minutes (until a transporter arrives sometimes) about not being able to tell them their results... the best defense for me so far has been "I just make the x-rays look good, and the Doctor gets to read them" or "would you rather have my 2-year education diagnose you or the Doctor's 12-year education diagnose you?"  Are you willing to risk your license and career to provide your opinion when a Physician will read the x-rays just a few minutes from the time of the exam?  I, personally, am not.


Pet Peeve #4 - The Complacent Technologist:

As a working Technologist (prior to any supervisory level experience), I have dealt with this a few ways.  Early in my career, I would simply ignore these Techs and work my rear end off, not worrying about the workload of those around me.  I kind of miss these days because I was getting paid to perform one patient exam at a time, and I didn't have to multi-task very much for the good of the department.  I knew that if I kept a good work ethic, I would find myself getting optimum raises and increased opportunities at work regardless of what other Techs were doing.  I quickly became known as "good with patients, dependable and hard-working"... a Supervisor's ideal employee.

Now that I am involved in leadership, I have a LOT more responsibility for the overall productivity of the department. Techs who go missing or take extra long breaks or lunches really take a toll on the department.  A Technologist who just wants to collect his/her paycheck, barely performing the duties within their job description, but never going above and beyond should not (in my humble opinion) be in the medical field.  When you are taking care of real people, leave your complacency at home folks!  Even if you work at a slower pace than your peers, you can have a huge impact on patient satisfaction of you enjoy your job, which all dwindles down to taking care of people.  I would rather hire someone who is lacking in some technical skills or efficiency, but who has a good attitude and strong work ethic, than someone who seems complacent.  Skills can be taught, but attitude cannot.

Pet Peeve #3 - Disrespectful Nurses:

I will start by saying that I have a huge respect for the work that Nurses do... in many ways, I feel that Nurses are tasked with caring for the patient, while the Physician researches what to do for the patient.  They are the front line between the patient and their Physician, and often do not get cooperation from Physicians, leaving them in an awkward role.

What I cannot tolerate is Nurses who are disrespectful to their patients and/or other staff members throughout the hospital.  I do not hesitate to write up any Nurse who neglects a patient (example: not changing soiled bed sheets for 4 hours).  I have been in the hospital with my kids too many times... the notion that we may get one of these "bad apples" as a Nurse for one of my children worries me.  I guess I have a personal bias for unprofessional conduct.

I recently had a conversation with a Nurse who felt competent to hire Radiologic Technologists because she was an "IR Nurse" 20 years ago.  I found this extremely insulting.  I said "well I was an IR Technologist about 7 years ago... do you think I am competent to hire a Nurse?"  In her eyes, being a Nurse required far more education and expertise than "pushing a button" did, and of course I wasn't competent to hire any Nurse.  All I'm asking for is a little bit of respect... some acknowledgement that I went through the same amount of specialized education than Nurses do, with (for the most part) an entirely different skill set at the end.  I don't ever claim that Nursing is "just hanging out with patients all day."  Mutual respect will go a long way in bridging a gap between departments as well as obtaining what should be our mutual goal of outstanding care for the patient.

Pet Peeve #2 - JCAHO Inspection

For those of you that don't know, JCAHO is an accrediting body for the hospitals which, once accreditation is received, provides a certain level of benefits including reimbursement for costs among other things.  Bottom line... if accreditation is lost due to a failed inspection, the hospital loses a lot of money - and it could mean many jobs, and in this economy, maybe even a near-future shut down of the hospital as a potential result.

It's not the inspection itself that bothers me, it's the attitude of hospital employees when they are made aware that JCAHO may be visiting.  People go into panic mode as if a tornado siren went off.  Frantic orders are placed upon employees to make sure everyone is doing everything by the book, supplies and drugs aren't expired, the best patient care is observed, work orders are properly placed for damaged equipment, cabinets are locked that should be locked, HIPAA is observed, and break times are logged... among many things I haven't mentioned.

The irony lies in that patient care is often impaired because attention is being focused so intently on all of these things.  I believe that it is good practice to run a mental checklist to make sure all of these things are being done properly, but not that anyone should be really stressed out about them.  All of these things should be done every day anyways, right?  I propose that the amount of panic, fear, and stress load is proportional to the belief that your hospital is not doing the things it should according to accreditation standards.  The more you think you're not doing things they way they are supposed to be done, the more your staff will stress out about a JCAHO inspection.


Pet Peeve #1 - Physicians not Explaining Exams

Part one of this pet peeve is failure of the Physician to explain the reason for the exam... this is difficult on two levels.  First, the patient may have no idea why the Physician ordered an exam.  This requires a large amount of time to determine through patient history and even possibly a phone call to the Physician to get a little bit more history on what he/she is looking for.  Second, the hospital will not get reimbursed for the procedure if there is not an accurate reason (stated on the prescription) for the exam.  The correct ICD-9 (soon to be ICD-10) code will not be provided, and the hospital has to suck up the cost of the exam.  Not a great way to go about billing with all of the health care reform and cuts in medicare reimbursement going on!

Part two deals with when a Physician orders an exam for a patient (a Barium Enema for example) and tells the patient they're "going for an x-ray."  First of all, patients hear this and think "my last x-ray was a chest x-ray, and that took about 10 minutes."  They may not make arrangements to be in your department for over an hour or expect the potential discomfort and recovery needed for some of the exams we perform.  The definitely don't expect the "upside-down volcano" that a bowel prep can cause, or any tampering with their rectum in the radiology department!  Half the time, they end up refusing the exam, or if they proceed, they get upset because they had an unpleasant and unexpected experience provided by you, the Technologist.  Two months down the road, negative comments come up on patient satisfaction surveys, and if the patient complains to the original ordering Physician about the procedure, that Physician may cause a stink over it at the administrative level (which eventually trickles down to the Techs) or the Physician may stop sending business to your hospital with enough complaints, unaware that they are part of the problem.

Doctors, you spent a large percentage of your life-time in school to help patients... you can start by speaking to them.  We want to help too!

To summarize, I think a majority of these personal pet peeves can be solved with the golden rule of simply treating people how you want to be treated.  And again, I do not intent to spew negativity, but as workloads increase with the cutting of costs and even work-force, we are all going to be a little more stressed in the next few years, and may be in the need of an outlet.  What are some of your pet peeves in your radiology department?

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Loopogram

I've only seen a handful of loopograms in my career, but every time I encounter the procedure, I am often in the company of Technologists and Radiologists who have never heard of or seen one.  So what is a loopogram? 

Whenever there is a large amount of bladder removed, usually due to Ca, the ureters can be connected to a loop of small bowel (ileum) which drains out of an ostomy (also called an ileal conduit) into an external drainage bag.  The x-ray exam involves placing a small foley catheter into the conduit and injecting contrast retrograde to evaluate the bowel loop, ureters, and kidneys.  The following supplies are needed:

• Iodinated contrast (we use Omnipaque 240)
• Small foley catheter - 10-12 Fr.
• Lubrication jelly for the foley
• 60mL cath-tip syringe for the contrast
• 5 or 10mL syringe for the foley balloon (if needed)
• gauze
• chux or towels to catch any drainage
• new drainage bag if needed
• gloves
• hemostat

Start by clamping the drainage bag, then removing it from the abdomen, making sure there are chux or towels underneath the patient's side of interest.  You should have the contrast drawn into the 60cc syringe with foley connected and contrast flushed through the catheter.  The Radiologist should apply the lubrication jelly, insert the foley and inject while the Technologist operates fluoroscopy and tends to patient needs.  Here are some images during a loopogram:


Initial injection of about 10mL with the foley balloon inflated.

About 15mL - beginning to see retrograde filling of ureters to renal pelvis on patient's right side.

Contrast seen in patient's left renal pelvis after 20mL injected.

Post-drainage KUB with drainage bag reconnected - showing retention of contrast.

A normal loopogram should not cause much pain, but possibly a little discomfort.  If there is pain, it could indicate extravasation of contrast from a leak.  Obliques are typically acquired (not shown here) and the contrast should drain on its own after the exam is completed.

Percent of Increase or Decrease

How to Become a Radiologic Technologist

There is a lot of misinformation going around the internet about what we do... and unfortunately, there are a lot of people looking to make money off of individuals who would like to become Radiologic Technologists, but may not know the difference between that and a "x-ray technician" or simply an "x-ray tech."

I subscribe to google alerts for "radiography", and this morning I received this link:  http://www.stridemagazine.com/what-is-the-yearly-salary-of-the-radiologist#comment-3346

It's not the first link that I have come across with loads of inaccurate information.  Its title reads, "what is the yearly salary of a Radiologist?"  As we know, a Radiologist is a Physician, but the article goes on to describe (mostly incorrectly) how to become either a Radiologic Technologist or a Limited Licensed Technician, unable to distinguish the two.

Let me just say that if you are currently in, or have graduated from a JRCERT - accredited x-ray program, possessing ARRT Registry, you went about it the proper way.  There are many schools popping up claiming to provide you the education to "be an x-ray tech" but lack the proper accreditation.  This infuriates me to no end.  I have met several students who found out they were not qualified to work in a hospital setting only after they paid a hefty $20k to one of these programs, and ended up enrolling in their local Community College program later.

As far as I know, there is no law against these schools doing this, but there is such a thing as false advertising.  Many schools come very close to this, and will tell you (verbally - not in writing) that you will be qualified to work in any hospital after completing their program.

I am writing this post specifically as a word of caution to those who are seeking to be Technologists, as well as to offer any assistance to those who would like to ask any questions about the process.  It is important to educate yourselves prior to enlisting in any school, and to know your options.  I am currently writing a book on the subject due to the massive amount of misinformation that is going around about it, but it will not be complete and/or published at least for another 6-8 months.  You shouldn't have to wait for this basic information though... let alone pay $20k to find out the hard way that the education you received is inadequate.  You should also be wary of the job market in your area for Technologists right now.  It's pretty tight, although the next 3-5 years are expected to really pick up due to the Baby Boomer generation retiring (which makes up the largest percentage of the work force in health care).  Please feel free to post questions here, or send me an email if you do not want your questions addressed publicly.

If you do not trust me as a source of information, you can go to www.jrcert.org where there is a database of Radiography schools searchable by state.  The contact information for each Radiography Program Director is there.  You can email or call them to find out how you can attend an information session, or get additional info on the program you are considering, but they MUST be listed on this website.

Tech Tips: Patient Identification

The number one patient safety goal in the country is proper identification of patients.  There have been many unnecessary procedures and/or surgeries performed on patients over the years that should have been prevented because one or more members of the health care team either neglected to, or were afraid to check the patient’s ID.

About 8 years ago, I performed an x-ray series on the wrong patient, and I will never do it again.  I was at an outpatient imaging center (where no wrist bands were worn).  I called the patient’s name, and an elderly woman stood up and followed me toward the x-ray room.  We were busy, so I didn’t bother asking for a date of birth because my paperwork said 80 years old, and she looked “about” that age.  BIG MISTAKE!!!  About one hour later, a patient with the same name inquired how long it would be from the front desk receptionist.  You can imagine the confusion that followed when I informed the receptionist that I already performed the x-rays on that patient.  After a considerable amount of time was spent sorting it out, I felt horrible because no one could identify the patient who I actually x-rayed (and who left an hour ago).  Being busy is no excuse!  Please learn from my mistake and verify name and date of birth in an outpatient setting with no wrist-bands.

I have heard exponentially worse stories of surgical teams who suspected that they were operating on the wrong patient, but were afraid to say anything because of a Physician’s demeanor.  Remember, you are the patient advocate just like everyone else on the health care team.  You can still check a wrist-band without making a big production, and you MUST inform the Physician if there is a discrepancy.  It’s not only the Physician that is liable, but every member of the health care team who came in contact with the patient, and should have confirmed ID.

You should always check the patient wrist-band in a hospital setting.  Two identifiers are required, but I suggest that three should be verified by all Technologists:  Patient name, date of birth, and medical record number.  If it is an outpatient, simply look at their wrist band while in the waiting room, and wait until you are behind closed doors to verbally verify ID.  Inpatients can be visibly checked in the hallway while waiting for an x-ray room to become available, but should also be verbally verified once in the exam room.  Please remember to protect their privacy.

It’s hard to admit that you have done something wrong, and sometimes it can be very painful, but no one will benefit from a mistake unless the error can be identified and steps are made to further prevent the same error in the future.

The Author's Paradigm

I'm sorry for my recent absence from the blogosphere... I have begun work on my own radiography book that has taken up quite a bit of my time.  I have this problem where I get really excited about a particular activity or project and I tend to spend all of my time and energy on that one thing.  This can be a great attribute when you are being paid to perform that task for an employer, but it can also make regular activities (like eating, sleeping, blogging, etc.) take a back seat, and for that, I apologize.

I definitely have some great posts coming up soon as I have gathered some new ideas.  I will be teaching a new group of students starting at the end of this month, and I would like to have more of the math tutorial videos for sample problems posted as examples to refer to for that group, as well as anyone else who needs to see some worked out.

As always, please feel free to shoot over topic suggestions, of if there is a particular discussion you would like to see among Radiographers or Radiography Students, please let me know.  Thank you for your patience!

Are There Too Many Radiography Grads?

There is quite the controversial discussion going on around town.  I have heard complaints from several students across the country, some of my own students, technologists in the hospitals and imaging centers, and even online in Radiology forums about how many new grads there are in the Radiologic Sciences Programs when there are "so few jobs" out there.  I have heard comments like, "the schools are saturating the job market" and "it all comes down to greed with college administrators."  I have even heard allegations that the hospitals pay off the schools to have students there, and vice-versa in a conspiracy to keep technologists who are already employed stuck in their current positions.  I think it's time to set the record straight on a few things.

I have never heard of any hospital or school having financial gain for their professional contracts.  That would be a huge conflict of interest.  To be perfectly realistic, there are some schools that don't look at the job market saturation and fill the seats in the classrooms with the motive of greed... but I think this is probably less than 1% of the cases in the United States.  The problems that hospitals and schools are facing on an administrative level has to do with a couple of things:  The upcoming surge of baby boomers retiring and the reduction in medicare reimbursement.

Baby boomers were born anywhere between 1946 and 1964, which means that by 2011, the first boomers will have reached age 65 - retirement age.  Unlike the last three decades, the healthcare field has made an effort to try to anticipate this reduction in work force, since the boomers make up the largest population of any age group in most hospitals.  They also make up most of the executive and administrative bodies.  Once they start retiring, there's going to be a large need for qualified employees to fill their shoes.  Also, the number of geriatric patients is expected to increase exponentially with this change.

How do the proactive efforts of the hospital systems contribute to increased graduates?  Well, most schools (typically community colleges) have a symbiotic relationship with the hospitals in their area.  For Radiography programs, there needs to be enough technologists to take on students, and there needs to be enough jobs when the students graduate in order to employ 75% of all new grads within 6 months of exiting their respective programs (JRCERT requirement).  The hospital administrators regularly communicate with college administrators to determine exactly how many graduates should be pumped out annually.

This all sounds great in theory... here's the problem.  More and more people are continuing to work into and beyond the traditional retirement age.  People are unsure about social security payout, and with the economy the way it is, a lot of people have lost money on their stocks, 401k's and other investments; basically, a lot of people cannot afford to retire yet.  The efforts made between the hospitals and schools are valiant and I commend those institutions that have been proactive, but these efforts relied upon information that was incomplete at the time.  Preparation for this scenario was started years ago and some of the variables have changed.

I have no doubts that this was a wise move, but it was conducted a few years too early.  Unfortunately, our market is rather saturated at the moment.  Those who do find jobs out of school are settling for undesirable positions as casuals for multiple employers and usually second or third shifts, weekends, and holidays.  Those unwilling to take these shifts or relocate are not able to find work.

The reduction in medicare reimbursement is a wild card.  It could serve to increase or decrease the demand for technologists... I happen to believe it will increase it.  One could argue that the more expensive studies like CT or MRI will not have the same reimbursement rate after reform officially kicks in.  Less expensive exams like diagnostic x-ray will increase in number, and reimbursement is more likely to be paid for the cheaper studies.  This may bring back additional volume to gen rad departments and take some volume away from advanced modalities.  Even if advanced studies are ordered, x-rays will probably have to be done first in order to show prudence that the cheaper study was attempted and found unsuitable to diagnose adequately.

Now is an awkward time for those who just graduated from a Radiography program.  I truly believe that the market saturation problem will slowly diminish over the next 5 years or so.  Now is the time to accept those unfavorable shifts and positions that require sacrifices that you might not have anticipated.  Get your foot in the door.  It will definitely pay off when the slump goes away and the more desirable positions need to be filled.  It's very competitive out there right now, but there will soon be room to grow and you will be thankful that you persevered through this difficult time.