Inbound phone calls from a referring provider to the reading room can be good for patient care, but they can also be deeply harmful. At best, these calls exchange valuable information, build trust, and strengthen your contract with the hospital. At worst, inbound phone calls to the reading room severely undermine patient care and productivity. Understanding the dynamics of inbound reading room phone calls will help you take immediate steps to minimize their harmful effects on your practice, whether you’re a resident, seasoned attending, or somewhere in between.
How do inbound calls destroy the reading room?
In 2014, Brad Balint and colleagues at the Indiana University School of Medicine studied radiology residents on call during a 13-month period. They cross-referenced phone calls to the reading room against the times at which residents had submitted preliminary reports. Their analysis showed that increases in the number of phone calls to the reading room correlated with diagnostic errors accumulated by radiology residents. In February 2017, Lauren Williams and Trafton Drew at the University of Utah introduced distractions during lung nodule assessment of chest CTs in the form of simple math problems that readers had to solve before continuing their visual search. The researchers showed that interruptions quantifiably resulted in lost time because readers forgot which parts of the anatomy had been reviewed.
Fortunately, we don’t need to fund a multi-center randomized control trial to appreciate the negative effects of inbound calls to the reading room. When your phone rings, you lose intense focus on the current case as you switch to the patient the call is inquiring about. Much of your work on the current case is lost. You haven’t reviewed this new patient’s images, and you’re expected to render a diagnosis on the new patient within seconds instead of minutes. This is a fundamentally different reading environment. The referring provider talks while you’re reviewing images. Their words steer your attention away from your normal search pattern.
When you put down the phone, you’ve lost much of your work on the previous case. You’re compelled to finish reviewing the new case while your phone discussion is fresh. You systematically review this new case and complete your dictation. Along the way, you’ve made new findings, and you’re required to call the referring provider back. Who did you talk with? What’s their phone number? For the next five minutes you’re wading through a phone tree so that you can document this discussion.
Fortunately, there are three practical concrete countermeasures you can take to handle these toxic effects, while keeping your referring providers happy and your patients safe.
1. Triage your own inbound calls
When you receive a phone call, ask whether the study can be reviewed in a few minutes or whether this is an emergency request. If call is non-urgent, ask if you can call back after you finish your current study, so that you can give the caller’s patient your full attention. That last part is important and honest– you’re signaling that you genuinely care about their case, and you’re deferring their call in order to give their patient your full, undivided attention. You’ll need to iteratively refine your tone of voice and messaging to effectively triage this patient into the safety of undistracted review while leaving your referring provider feeling respected and valued.
You may not want to ask about the clinical indication on this call, which will prematurely launch a detailed description from the referring provider. Before you hang up, do get this information:
▪ Patient name, MRN, type of study
▪ Level of urgency (i.e., how soon do they want you to call back)
▪ Referring provider name and a direct way to contact them, whether it’s a hospital-issued wireless handset, pager number, or cell phone number
Write this information down on a paper notepad using pen. On a computer, you could suddenly lose your list, and you may be violating HIPAA by storing patient information on a shared desktop. A paper notepad is better than loose paper, because it has some weight so it won’t go flying off the desk into the recycling bin. You can use checkboxes to create a visual queue of things you need to catch up on after you finish the current case. After your shift, tear off your pages and get them to the shredder box.
What’s the hard part about this strategy? Remembering to look at your triage list. Fortunately, you’ll get better at this with practice.
2. Have someone else triage your calls
Back in 2014, radiology residents at Stanford recognized the harmful effects of phone calls, and they set out to fix it, just when continuous quality improvement was being popularized in the department. Through simple observation and charting, the residents determined that phone call intensity was greatest for residents on call, roughly during the 5pm — 1am time slot. This isn’t specific to Stanford — most radiology practices operate on a skeleton crew during the off-hours. As a result, calls that are distributed across the entire radiology department before 5pm are concentrated like a death ray onto one or two radiologists after 5pm.
Presenting this data to administration, the Stanford residents argued for a reading room assistant join their team. Years before, the ER residents and attendings at Stanford had adopted the use of scribes that fielded their phone calls and charted while they focused their full attention on patients. Similar to scribes hired into the ER, the proposed radiology reading room assistant would field and triage calls. Radiology residents could focus on rendering diagnoses accurately and efficiently. The residents were articulate, and the administration was persuaded to introduce these assistants. The effect of reading room assistants was immediate and positive. There was genuine joy and relief in the ability to focus on achieving high quality reads without incessant interruption. The reading room assistant service expanded to daytime coverage.
If your practice isn’t already using reading room assistants during your shifts, you might be able to suggest change through various approaches. Point to other institutions like Stanford or private practice groups that already use reading room assistants. An M&M conference might be an opportunity to (tactfully) discuss phone calls and their effect on patient safety. The ABR practice improvement requirement could be focused on this issue for a given year. There’s also a strong business proposition here — delegating to reading room assistants is the same reason lawyers engage admins to prepare documents or research assistants to perform initial investigations. For radiologists, in exquisitely quantifiable ways, time really is money. All of these arguments are rational, but the overwhelming reason your group might not have reading room assistants could relate to group culture, financial considerations, or politics, so don’t break yourself trying to effect change through rational argument.
3. Develop radiologist-centered scheduled chat software to eliminate inbound calls
More practices are now trying out chat windows, initially to facilitate consultation between radiologists about a case, but also between reading room assistants and radiologists. Existing chat window solutions provide alternatives to a ringing phone, but they still represent unscheduled interruptions in study interpretation. These solutions are primitive at best, and they aren’t created with the radiologist and referring provider at the center of the design process.
The chat software we really need to eliminate phone calls hasn’t been invented yet, but it’s possible to speculate what it would look like. We use work lists to triage the next study we review. Imagine work lists that queue consultation requests from referring providers. The referring provider would submit a form to request the consultation and indicate the level of urgency. The request would be listed and ranked in a work queue. If the consultation request relates to a study that’s already been read, it could be routed to the interpreting radiologist. Radiologists could otherwise pick off the consultation queue in between cases. Practice groups would assign RVUs to that activity so that radiologists are rewarded for engaging in consultation. This advanced chat solution doesn’t exist yet. If you’re looking to design this product, start with radiologists and other providers at the center of your design process.
The Bottom Line
As a practicing radiologist, you know that inbound reading room calls are sometimes helpful and frequently distracting. By triaging these calls effectively, you’ll be on your way to strengthening your professional relationships with referring providers and giving your patients the best possible care.
Do telephone call interruptions have an impact on radiology resident diagnostic accuracy?
Balint BJ et al., Academic Radiology, 2014 Dec; 21(12):1623–8
Distraction in diagnostic radiology: How is search through volumetric medical images affected by interruptions?
Williams LH and Drew T, Cognitive Research: Principles and Implications, 2017; 2(1): 12.
Ram Srinivasan MD PhD is a practicing radiologist in Palo Alto, California. He designed Orbit as the most seamless way for doctors, PAs and nurses to earn CME/CE while focusing intensely on patient care. Learn more about how Orbit’s plugin helps you earn CME for the browsing you’re already doing at work and join your colleagues in Orbit today at orbitcme.com.