In the past, I’ve shared some humorous memories from my radiology residency, particularly the quirky experiences during call shifts. After a certain hour, our radiology team scaled back, leaving only the essential overnight staff. During these times, if an emergency department or another clinician declared an overnight case as urgent, it fell to us on-call residents to decide whether the on-call technician needed to be brought in for the procedure.
The absurdity of this setup lay in its illusion of authority. Everyone knew that we didn’t have any real power. Our role involved creating some resistance within the system. Any clinician who was set on handling their “emergency” right at that moment knew they just needed to contact the attending radiologist. If the attending wasn’t convinced, the matter would escalate up the chain of command – from the section head to the department chair, and beyond.
For both us residents and the attendings, the decision-making process was straightforward: agree to the request, and you could quickly return to your activities or rest. Opposing it meant engaging in fruitless arguments and eventually being overridden by a higher authority. Yet, agreeing had its drawbacks too, like dealing with irritated technicians or receiving a critique the next day from an attending who might have easily taken the same path during the wee hours.
We new residents quickly realized how wasteful it was to activate a tech for a non-critical exam. The rationale for unnecessary ultrasound requests often went along the lines of, “If it’s positive, we’ll take the patient to surgery immediately!” Almost invariably, regardless of the ultrasound outcome, they would still demand an emergency CT scan. After experiencing this cycle enough times, any resident would feel compelled to question its logic: why insist on an ultrasound that never affects the next step, and why involve us in this charade?
Some of us tried to ask the clinicians for explanations, hoping to find a logical reason. Alternatively, some of us had already concluded there was no valid reason and wanted to see how the clinicians responded. Often, our inquiries led to awkward exchanges, confirming our suspicions.
Although we were involved, we remained outsiders compared to those directly entangled: the patient, their family, ER, or surgical staff. Our insights were more indirect, yet we drew some solid conclusions.
First, we often felt as though the emergency clinicians lacked direction in their decisions. Furthermore, it seemed that surgeons or other specialists delayed their involvement by requesting more diagnostic tests. It was a likely tactic to postpone visits until the morning.
Looking back, we may have been right all along. The scenario, repeated countless times, didn’t offer many alternatives. One would expect that responsible clinicians would want to convey their competence by explaining their reasoning. Their silence or lack of justification, then, seemed a tacit admission of inefficiency.
After finishing my residency, I didn’t encounter precisely the same environment again, though the facade of “required exams” continued to appear in my work. Just recently, I was reminded of residency days when a “rule out appendicitis” ultrasound for a child led to an unmistakably positive result. Yet, a CT scan followed a couple of hours later, confirming the same diagnosis.
Over the years, someone introduced me to a critical line of thought: if you know a situation only partly and it leads you to a single conclusion—like assuming the ER is clueless—you’ve likely missed some perspectives.
In such events, I try to stretch my imagination. Whether plausible or not, can I devise alternate explanations? By brainstorming more scenarios, I tend to develop fewer negative impressions of others.
Here are some reflections on seemingly needless procedures like the ultrasound for appendicitis:
One possibility is that someone in the ER or surgery is conducting research comparing ultrasound to CT scan effectiveness, needing more cases for study. Though this research may seem redundant, science is rarely settled.
Alternatively, the delay in decision-making might stem from cautious parents hesitant about consenting to surgery. Additional evidence via imaging could alleviate their reservations. They may have initial concerns about radiation exposure, but a positive ultrasound could shift their mindset.
Another scenario might involve a change in the patient’s clinical condition between tests. Improvements might deem intervention unnecessary, while worsening symptoms—like concerns over perforation—justify additional imaging.
Lastly, logistical issues might account for the redundancy: an overloaded CT department or technical challenges might make ultrasound the initial option. But once CT becomes available, the scan proceeds despite resolved issues, sometimes due to a lack of communication across teams.
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