Spoken vs written conversations:

Lorri Zipperer Lorri at ZPM1.COM
Thu Aug 15 20:52:26 UTC 2013

Fw w/new subject heading by moderator -- 


From: Swerlick, Robert A [mailto:rswerli at emory.edu] 
Sent: Thursday, August 15, 2013 2:07 PM
To: Society to Improve Diagnosis in Medicine; Karen Cosby
Subject: RE: [IMPROVEDX] Errors in Oncology Pathologies


I am not such an enthusiast when it comes to spoken vs written
communications. In my experience what is spoken may be very different from
what is heard and what is initially heard may be very different from what is
remembered. Spoken communications have a relatively short half lives. That
is the reason we generate written reports. Conversations are useful but the
information conveyed may be inconsistent and non-enduring. They are
certainly better than no communication whatsoever. 


Bob Swerlick


From: Karen Cosby [mailto:kcosby40 at gmail.com] 
Sent: Thursday, August 15, 2013 3:08 PM
Subject: Re: [IMPROVEDX] Errors in Oncology Pathologies


I agree with Dr. Gordon (and of course I am a practicing emergency
physician).  Listening to this dialogue, I am surprised how awkward the
exchange of clinically relevant information is when it is indirect, say via
a search of the medical record or review of an order. Whenever possible I
find a first hand conversation is the most effective way to yield useful
information.  Both sides can ask questions, discuss nuances of the case, and
question each other's findings.  Back when I was a student and attended
"tumor board" I was amazed at how often pathologists and radiologists
altered their opinion when provided background and context.  Many of the
significant errors I've seen reported have to do with generalists
mis-interpeting written reports or specialists not fully understanding
clinical context.  Why is our practice designed to make a conversation the
exception rather than the rule? 


On Wed, Aug 14, 2013 at 3:07 PM, David Gordon, M.D. <davidc.gordon at duke.edu>

I wanted to share some other thoughts in hope of contributing to this very
useful discussion. This comes from the perspective of an emergency physician
practicing at an academic center with many radiology interpretations coming
preliminarily from residents - not board certified attendings, so not all of
this may be generalizable to practice at-large.  (I also can't speak to how
this applies to pathology as I do my best to avoid these services in my line
of profession).

1) In terms of measuring overall diagnostic accuracy in radiology, I wanted
to echo a point made by Stefanie Lee in a separate thread that there can be
value in engaging the radiologist prior to the study being performed to make
sure the correct study has been ordered in the first place (e.g., a chest CT
to evaluate for pulmonary embolism will be protocolized differently for one
to exclude aortic dissection).  I have a general sense for the protocols out
there, but also know there are times where I need to confer with my
radiology colleagues.   So in asking overall  whether clinical information
helps or hinders radiologic diagnosis, not only correct image interpretation
but also correct study acquisition should be considered.

2) I take a variable approach in terms how much information I provide to the
radiologist and more specifically whether I just provide "clinical data" or
additionally provide a preliminary "clinical impression."  This is based on
whether the patient is still broadly undifferentiated or whether there is a
specific disease process I am worried about. I always provide clinical data
(e.g., location of pain, presence of fever, leukocytosis,...) and if the
patient is undifferentiated  that is all I provide. If, however, there is a
diagnosis jumping out at me that I am specifically looking out for, I will
also include this preliminary impression  in the form of "concern for..."
Perhaps never providing a clinical impression will prove to be best, but I
wanted to toss out the idea that how differentiated a patient is prior to
the radiologic study may be an important variable.

3) In terms of asking overall what model of information exchange will
provide the best diagnostic yield, I wanted to toss out the role of the
clinicians looking not only at the impression of the radiologist but also
the images themselves. This may be more relevant at a teaching hospital and
more feasible in an emergency medicine setting where the time frame is
condensed, but by looking at the area of interest that correlates with
concerning physical exams findings, we have had good "catches."  It has
forced the review of specific images that broadly "just don't look right" to
the emergency medicine physician.  This is typically done after the
radiologist has viewed the images independently to avoid bias. For unclear
or complicated cases, going over the clinical data as well as images
together may be an important step.


David Gordon, MD
Assistant Clinical Professor
Division of Emergency Medicine
Duke University

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