Embracing Risk Adds Value

There's a simple way to define value: Ask why imaging exists.


June 2015

Imaging exists because clinicians are uncomfortable with uncertainty. Imaging exists because emergency physicians feel that being 98 percent correct about the absence of pulmonary embolism is not good enough.

Radiologists exist because imaging is not an assay on a Western Blot with 100 percent accuracy. Radiologists exist because information is imperfect and clinicians do not like imperfection. This means when reading a CT scan for acute appendicitis if, instead of decreasing the uncertainty of the condition’s absence, we increase it, we are doing clinicians a disservice. When we say we “cannot rule out minimal early sub-clinical tip appendicitis,” what we are really saying is, “We do not wish to share your risk. You’re on your own.”

When we produce a litany of differentials and disclaimers in our reports, so that the clinician, who gave us a contract to reduce uncertainty, is even more uncertain, we are like Tony Montana from “Scarface,” who took money for a kill and then changed his mind. (By the way, he dies in the movie.)

The emergency physician orders a CT for pulmonary embolus because she cannot rule out a pulmonary embolism without it. She does not enlist our help to hear this philosophical truism repeated. So when we tell her that “small isolated sub segmental pulmonary embolus cannot be entirely excluded with absolute certainty,” we are having our cake and eating it too. That is, we are taking money to stick our neck out, but we are not really sticking our neck out.

If we are uncomfortable sticking our neck out, we shouldn’t have done the CT. It’s like a builder charging for time and material to build a roof, playing around with the material, and then saying it’s the roof that can’t be built. If the builder had said so in the first place, we likely wouldn’t have wasted money on the material and paid for his time. Of course, there will be occasions when we should say, “Cannot rule out,” but these times should be few and far between. Such occasions cannot be precisely defined. Guidelines cannot stipulate the circumstances in which “rule out” should or should not be used. We will have to defer to judgment. Unfortunately judgment can’t be specified. If it could, it wouldn’t be called judgment.

Judgment can be neither commoditized nor outsourced. Judgment means risk. Risk means value.

Of course, there’s risk of being sued when we use our judgment. Would we want it any other way? Think about it. If there’s no risk, why should we get the big bucks? A nurse documents “MD informed” because there’s merit in our being informed. It’s because we are physicians. It’s because we can be sued. We can be sued because people pay attention to what we say. This is the Hammurabi Code, which outlined standards of contracts more than a thousand years ago.

Want a safe harbor? Want to be guarded by having process defined to the letter? Want our jobs to be reduced to a 10,000-page user manual? Want thresholds to define every pathology incontrovertibly? I say sure, go for it. In the short run, there will be security. Lots of security. In the long run, we will be replaced by people who work faster, work for less, are more compliant, and can never be sued. Hurrah!

There will always be a hamster willing to run faster on the wheel for less money with a larger risus sardonicus on the face. “What can I do to deliver outstanding service today?” they will say. Don’t compete with hamsters. They will win.

Judgment can be neither commoditized nor outsourced. Judgment means risk. Risk means value. Refusal to accept risk is the opposite of value. Actually, it’s worse. It means not doing our job.



Getting Started

Looking to improve your reporting and communication skills? A good place tobegin is the RSNA Radiology Reporting Initiative, a resource that provides report templates for all subspecialties. Read more about standards and guidelines for radiology reporting in JACR®’s “Quality of the Written Radiology Report: A Review of the Literature."

By Saurabh Jha, MBBS, an academic radiologist who studies the value of imaging and encourages arguing for pedagogic benefits. Opinions expressed are those of the author and do not necessarily reflect the position of the ACR.



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