I would like in this essay to delve into the subject of the radiologist’s interaction with referrers. In the preceding discussion I hinted at this obligation. What is most important about our tasks for the sake of our patients was not just the interpretation of findings but also the character and quality of the physician-to-physician transactions that followed from your observations as manifested in your reports. Moreover, our responsibility is not limited to the recognition of abnormalities. It is concerned, too, with the integration of our expertise with other elements of care. For that we needed to consult with referrers and, more to the point, to make those exchanges central to our daily work.

But in our assessment of the essentials of practice, I have noted a subtle deviation from that aim toward another function that some might consider similar or, at least, analogous to our consultative responsibilities. Yet it is one which when substituted for consultation often lessens our value to a degree and therefore diminishes the excellence (or at least the pertinence) of the care we can provide. That distinctive outreach activity is verbal communication. It is such a common exercise why should anyone criticize it. Let me try.

Much is made of our relationships with other physicians through directed communication. It is the focus of policy statements by our leaders articulated through regulations and recommendations. Nonetheless, by itself a communication can certainly disseminate information but it also, in its conventional format, imposes uncertainty and risk, two untoward consequences consultation largely obviates. I will attempt to explain this issue by undertaking a detailed analysis of the ambiguities inherent in the ACR’s guidelines for the Communication of Diagnostic Findings, specifically the latest iteration of them promulgated in 2005.

In the first paragraph of the preamble to these guidelines a disclaimer is provided. “They are not inflexible rules or requirements of practice and are not intended, nor should they be designated to establish a legal standard of care”. Unfortunately, that is wishful thinking because these guidelines are often invoked by plaintiff lawyers as the written embodiment of the standard of care, useful in providing a touchstone to which a defendant radiologist may fail to adhere. So with the specter of legal proceedings in mind we must regard them for their prescriptive implications and not merely as advisory messages.

Here we have the crux of the matter. It is the replacement of our potentially consultative role supplanted by an often more flexible means of offering information, through pronouncement instead of colloquy. In that regard, my attention with this set of guidelines is focused on section C. 2 entitled Non-routine Communication. It is described as occurring in “emergent or other nonroutine clinical situations” for which “the diagnosing images should expedite the delivery of a diagnostic imaging report (preliminary or final) in a manner that reasonably insures timely receipt of the findings”. There are three distinct situations in which there would be a need for non-routine communication. The first two are obvious i.e., first a finding in which is demonstrated a need for immediate or urgent intervention and, second, an observation that is different from a preceding interpretation. The third situation is the one that stimulates the most malpractice suits. It relates to “Findings that the interpreting physician reasonably believes may be seriously adverse to the patient’s health and are unexpected by the treating or referring physician”.