Out of the Dark

The Johns Hopkins Radiology Resident Consult ServiceJohn Hopkins

Advancements in imaging technology in the last several decades have ushered in a new golden age of radiology. The development of PACS, new imaging modalities, and new protocols and techniques has greatly improved our ability to serve our patients and our referring providers.

Unfortunately this runaway freight train of innovation came with a cost — decreased interaction with referring clinicians. Imaging in the pre-digital world was only visible where the radiologist sat. If a clinician wanted to review a radiograph or cross-sectional study they had to march into the dark cave that was the radiology reading room. With images available digitally, the days of daily imaging rounds all but disappeared across the country. Soon that dark cave of a reading room only got darker… and quieter. In addition, with all of the new modalities and protocols emerging, knowing what specific study to order has only gotten harder.

The ACR astutely recognized these unintended consequences of our technological awakening and developed their Imaging 3.0® campaign. The initiative encourages radiologists to increase their role as imaging consultants in order to better serve clinicians and patients alike. Clinical Decision Support (CDS) tools have been developed across the country to help decision-making at the point of ordering, but have had varying degrees of success. As good as our technology is, our expertise and ability to weigh clinical information is vitally important to proper image utilization. Ordering the right study at the right time in the right way is essential in a world of increasing health care costs.

In July 2015, the then fourth year radiology resident class at Johns Hopkins, recognizing the need for more referring physician interaction, established a new Johns Hopkins Radiology consult service, run entirely by fourth years. The idea to use fourth year residents as consultants was simple — fresh off a successful mastery of the ABR Core exam, senior residents possess the knowledge of a true general radiologist, able to answer imaging questions that span organ systems, departments and modalities. Each fourth year resident carries the consultation phone for a week at a time (Monday through Friday, 8am-5pm) while they continue their regular clinical duties. Providers are able to call the phone directly as well as use a web-based form through our hospital paging service. To get the word out, e-mails were sent (and recently re-sent) to faculty members, program directors, house staff, and community providers. For providers outside the Johns Hopkins system, calls and pages that are received after hours are returned the next business day, while in-house providers are directed to the on-call resident.

Key information about each consultation is continually recorded for quality control and research (including patient presentation/diagnosis, provider question, and resident recommendation). The consult resident is welcome to call faculty members with any questions/issues. The program director regularly reviews the entries to ensure a high standard.

The majority of the consultations have been related to which exam or protocol to order (65 percent from July to December 2015). Questions pertaining to intravenous contrast comprised 14 percent over that same time period. Approximately 9 percent of consultations were related to questions about a previously finalized report/examination.

The feedback from our referring clinicians has been outstanding, but getting the word out about the service has been the biggest challenge. Integration with our EHR at the point of ordering is currently under development to further increase the visibility and usage of the service. It is a great learning experience for fourth year residents and will no doubt help as we continue on as fellows and attendings. Not only does direct consultation bring radiologists back out of the dark, but it helps cut down on unnecessary examinations and helps better serve our patients. In the ever-changing health care climate, it’s a role worth taking back.

Brandon Childers, PGY-5 Radiology Resident, The Johns Hopkins Hospital

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