Resident is yelled at by a consultant - realistic
This is the realistic script, under development. Click here to read the original scenario submitted by LauraS, as well as the comments and votes.
INT. RADIOLOGISTS OFFICE, LATE FRIDAY AFTERNOON
RESIDENT knocks on door and sticks head in.
Resident
Hello, Dr. Lovall?
Radiologist
(Looking up from computer)
Oh hi, Kim, what's up?
Resident
(enters)
well, I was just down on 7B with Dr. Chen and Dr. Williams, and we have a 17 year old man with suspected osteomyelitis of the distal tibia that is likely chronic. So, we would like to request a semi-urgent MRI.
Radiologist
(raises eyebrows)
Oh, really... an urgent MRI for a chronic condition. (sarcastically) That sounds logical.
Resident
(awkward pause, then checks clipboard for notes on patient)
Well, he has had fevers, pain and redness been unwell for three weeks. (hesitates) The xray was normal, and the bone scan was equivocal. (pause)
radiologist
(hesitates, then when it's clear the resident has nothing else to say)
Ok, that’s great, but I’m still not clear on how an MRI is going to change your management of the patient, and more importantly, why it needs to be done urgently.
RESIDENT
Well, I think, um... (pauses again, trying to collect thoughts)
RADIOLOGIST
(with mild but increasing irritation)
Are you maybe planning to take him to the OR some time soon?
(starts shutting down computer, and packing up to leave the office)
RESIDENT
Oh - yes, that’s it. He’s not responding to first line therapy, and we want to see if there’s a focus like an abscess or something that could be drained to give us an organism
RADIOLOGIST
(mocking kind of sarcastically, continuing to prepare to leave)
Like an abscess or something. I see. Well, I guess that where Dr.Williams is from, they might actually do an urgent MRI to chase down an "abscess or something" without any kind of certainty about how the study is going to affect management of the patient. And maybe Dr. Williams or Dr. Chen would be capable of persuading me to bump someone off the current list - someone who has been waiting - oh, let’s see - three months or so.
(trying to contain irritation, but failing)
But I’ve gotta be honest with you, Kim, you are not doing such a great job of persuading me.
(smiling falsely) In fact, honestly? you’re kind of bombing. But hey, you’re doing an excellent job of making me late for grand rounds, though.
(starting to walk away, turns)
Get Dr. Chen to call me.
Script type:
realistic
What's happening?
Feb 22 2012 (All day)
Nov 12 2011 - 9:30am
Comments
Some withering comment that breaks down the conversation
Such as
"Its ridiculous to consider a CT scan for a headache like that. Why don't you prescribe a couple asprins instead?"
If wanting to keep MR as request
http://www.physorg.com/news186647264.html
Suggests inappropriate requests include lumbar spine MR for acute back pain, and knee or shoulder MRI in patients with osteoarthritis.
should be an appropriate request (?)
A more challenging scenario is one where the request would be considered appropriate - for example, the imaging requested would usually be considered standard of care in most centers - such as use of MRI in assessing a complicated or poorly responding osteomyelitis (Infect Dis Clin North Am. 2006 Dec;20(4):789-825.)
This is where I have seen the most difficult communications.
The team having made the decision to request the MRI / CT is aware of the evidence and why they want it, but perhaps the resident speaking with the radiologist is less certain of why it is needed and can't come up with an evidence based justification on the spot.
Excellent contribution
Thanks Laura -
This is excellent - especially with the contribution to the script. It would be great to include enough hints to show the resident's asssessment and request was legitmate, for the next phase when when we replay the scenario with an empathic script. For example that abcess is serious enough to warrant the MRI (perhaps already built in to the script "osteomyelitis...chronic...?), and that other diagnostic tools (ultrasound?) would be less appropriate.
I can our resident having sound intuition, so that even with his lack of confidence in approaching the radiologist, with a bit of sensitivity from the radiologist, they are able to ascertain that in fact an MRI ought to be scheduled.