Friday, August 17, 2018

Patient worries after accessing his chest x-ray report online

I received an email a few days ago. It has been edited for length and clarity.

I would like some advice please. I am a 46-year-old male with an off and on cough for 4-5 months. I have never smoked. After my primary care physician examined me, he ordered a chest x ray. A few days later I got a call from the doctor who said my x ray was normal. I was happy to hear that, but I am enrolled with My Chart which allows you to review your results online. Well, I read it and to me it doesn't sound what you would call totally normal, but I have no medical training so I could be wrong. I copied and pasted the report from the radiologist below. What concerns me is the "elevation" he refers to and using the word "fairly" clear lungs. Should I ask for another test or see another doctor for an opinion? If I was your family member would you suggest looking into this more?

CLINICAL INFORMATION: Cough

FINDINGS: The frontal view demonstrates fairly clear lungs with slightly increased elevation of the left hemidiaphragm compared with the prior study. This may be at least partially caused by air in the adjacent bowel. No pleural effusion or pneumothorax is noted. The cardiomediastinal silhouette is unremarkable. The lateral view demonstrates fairly stable appearance of the lung bases compared with the previous study.

IMPRESSION: There is no clear indication of acute cardiopulmonary disease on this exam. Increased elevation of the left hemidiaphragm, possibly due to air in the underlying structure, likely the fundus of the stomach.
__________________________

Thanks for your email.

There is equivocation in almost every sentence. I told the writer not to worry about it and said, “The radiology report says in a roundabout way that your chest X-ray is normal. A normal chest X-ray rules out a number of significant lung diseases.” I wished the gentleman well.

Rather than go on about this further, I consulted my friend Dr. Saurabh Jha (@RogueRad), Associate Professor of Radiology at the Hospital of the University of Pennsylvania. Here are his thoughts:

With patients accessing their reports more, it is even more important for radiologists to be clear. But this report is painful to read, introduces unnecessary uncertainty, promises stability when stability is not the issue, tries to be clever with words and phrases. Unfortunately, this is a consequence of reporting culture in which radiologists feel compelled to say everything they see, and qualify everything they see. I dread to think what'll happen when reports start quantifying everything.

The standardized format doesn't help matters because it forces radiologists to comment on the "cardiomediastinal silhouette” (makes it sound like a ghost) merely to say the "cardiomediastinal silhouette is unremarkable." FFS! Why remark on it?!

Here's how I'd have written the report, if I thought the elevated hemidiaphragm was clinically irrelevant.

"Normal lungs—elevated left hemidiaphragm unlikely to be clinically relevant."

I'd give this report 1/10.

Awful report, Skeptical. Thanks for raising my blood pressure this morning.


17 comments:

Ileana Balcu said...

Hi,
I'm a patient, an e-patient actually, so I probably read more medical literature than your regular patient... I have colonoscopies done often and I have access to the reports. below are two examples of reports. To me, one is scary and obscure, one is complete and more clear. It shouldn't be so hard to create the second kind of report, or even better, have a complete patient summary (with what was checked) to begin with, and then include the full technical report below.
I'm attaching the reports stripped of any patient info below:

Report 1 - scary and unintelligible - all I know is that there's no cancer (This happened in 2017, so it's not a process improvement)

FINAL DIAGNOSIS:
PART A COLONIC MUCOSA WITH LYMPHOID AGGREGATE.

PART B COLONIC MUCOSA WITH LYMPHOID AGGREGATE AND CRYPT ARCHITECTURAL
DISTORTION.

PART C COLONIC MUCOSA WITH LYMPHOID AGGREGATE AND CRYPT ARCHITECTURAL
DISTORTION.

PART D COLONIC MUCOSA WITH CRYPT ARCHITECTURAL DISTORTION.

PART E COLONIC MUCOSA WITH FOCAL CRYPT ARCHITECTURAL DISTORTION.

PART F COLONIC MUCOSA WITH MODERATE TO MARKED ACUTE AND CHRONIC INFLAMMATION
WITH CRYPTITIS.

PART G COLONIC MUCOSA WITH MODERATE ACUTE AND CHRONIC INFLAMMATION WITH
LYMPHOID
AGGREGATES AND FOCAL CRYPTITIS.

COMMENT:
There is no evidence of dysplasia in any of the biopsies.

Report 2 - more complete and clearer for the patient - definitely a better report (in 2016, same hospital)

FINAL DIAGNOSIS:
PART A TERMINAL ILEUM, BIOPSY:
SMALL INTESTINAL MUCOSA WITH PRESERVED GLANDULAR AND VILLOUS ARCHITECTURE. NO
ACUTE INFLAMMATION IS SEEN. NO INCREASE IN INTRAEPITHELIAL LYMPHOCYTES
IDENTIFIED.

PART B CECUM, BIOPSY:
COLONIC MUCOSA WITH PRESERVED GLANDULAR ARCHITECTURE. LYMPHOID AGGREGATES ARE
SEEN IN THE LAMINA PROPRIA. NO ACUTE COLITIS IS SEEN.

PART C RIGHT COLON, BIOPSY:
COLONIC MUCOSA WITH MILD GLANDULAR DISTORTION. INCREASED CHRONIC INFLAMMATORY
CELLS ARE SEEN IN THE LAMINA PROPRIA. THERE IS FOCAL INTERSTITIAL ACUTE
INFLAMMATION, CRYPT ABSCESS FORMATION AND ACUTE CRYPTITIS CONSISTENT WITH A
CHRONIC COLITIS, MILDLY ACTIVE. NO DYSPLASIA IS SEEN.

PART D TRANSVERSE, BIOPSY:
COLONIC MUCOSA WITH MILD GLANDULAR DISTORTION. INCREASED CHRONIC INFLAMMATORY
CELLS ARE SEEN IN THE LAMINA PROPRIA. THERE IS INTERSTITIAL ACUTE INFLAMMATION,
CRYPT ABSCESS FORMATION AND ACUTE CRYPTITIS CONSISTENT WITH A CHRONIC COLITIS,
MILD TO MODERATELY ACTIVE. NO DYSPLASIA IS SEEN.

PART E DESCENDING, BIOPSY:
COLONIC MUCOSA WITH MILD TO MODERATE GLANDULAR DISTORTION. INCREASED CHRONIC
INFLAMMATORY CELLS ARE SEEN IN THE LAMINA PROPRIA. THERE IS INTERSTITIAL ACUTE
INFLAMMATION, CRYPT ABSCESS FORMATION AND ACUTE CRYPTITIS CONSISTENT WITH A
CHRONIC COLITIS, MILD TO MODERATELY ACTIVE. NO DYSPLASIA IS SEEN.

PART F SIGMOID, BIOPSY:
COLONIC MUCOSA WITH MILD TO MODERATE GLANDULAR DISTORTION. INCREASED CHRONIC
INFLAMMATORY CELLS ARE SEEN IN THE LAMINA PROPRIA. THERE IS INTERSTITIAL ACUTE
INFLAMMATION, CRYPT ABSCESS FORMATION AND ACUTE CRYPTITIS CONSISTENT WITH A
CHRONIC COLITIS, MILD TO MODERATELY ACTIVE. NO DYSPLASIA IS SEEN.

PART G RECTUM, BIOPSY:
COLONIC MUCOSA WITH MILD GLANDULAR DISTORTION. INCREASED CHRONIC INFLAMMATORY
CELLS ARE SEEN IN THE LAMINA PROPRIA. THERE IS INTERSTITIAL ACUTE INFLAMMATION,
FOCAL CRYPT ABSCESS FORMATION AND ACUTE CRYPTITIS CONSISTENT WITH A CHRONIC
COLITIS, MILDLY ACTIVE. NO DYSPLASIA IS SEEN.

COMMENT:
The findings in Parts C-G are compatible with an inflammatory bowel disease.
Clinical correlation is necessary.

lp said...

I’d give it a 0/10 for omitting “correlate clinically “ and “consider CT chest.”

Korhomme said...

We used to have radiologists who were very concise in their reporting. For an x-ray such as this, the entirety of the report would be, 'Normal'.

Anonymous said...

This becomes a lovely symptom of a trust problem it think... We want to view the reports because we can't quite trust the expert we (oh wait sorry our "insurer" who we don't trust) pays for. The radiologist doesn't trust that their expertise won'g get them in lawsuit hell... And how the heck do you decide who should be trusted to be "Correct"...

Anonymous said...

There is a reason we physicians are considered "experts" in the field of medicine. Between the patient's PCP (internal medicine), Skeptical (surgeon), there was NO question what the x-ray report says. The radiologist's wording may be a bit obtuse, but anyone who went through 4 years of medical school plus additional training can read through the lingo.

Do you really want to see a day when patients themselves manage their own problem without the "expert" guidance of the physician?

Skeptical Scalpel said...

Patients already have access to their records online. That's not going to change.

I guess it comes down to whether you want clear, concise readings or muddled reports that cause patients to raise questions like the ones in the post.

Old FoolRN said...

Hi Dr. Skeptical
So happy to see you are now offering medical advice. I have this very embarrassing GI problem that seems to be loosely associated, so to speak, with consuming copious amounts of burritos and..well, never mind!

artiger said...

I have the answer. Patient can have access to radiology reports, but must come in for an office visit for any questions about the report. No phone calls, emails, or texts to discuss (unless billable). Fair enough?

Skeptical Scalpel said...

Honestly, I don’t think that’s fair especially if the office visit would be charged. You bring up a good point. What is fair? You can’t talk to a lawyer with paying for it. Yet doctors don’t charge for phone calls.

artiger said...

That's what I mean, Scalpel, why isn't it fair? Lawyers do it. Accountants do it. Let's quit trying to pretend that providing health care is doing the Lord's work. The Lord ain't paying us, Medicare and Big Insurance are.

Anonymous said...

Review your own records at your own risk. If patients choose to need more info than they can understand and choose not to believe the concise answer the doctor gave them they should also be willing to investigate the results. Oh wait, this guy did his investigation by asking Skeptical!

Skeptical Scalpel said...

Artiger, life is not fair. I don't see any way the public will accept paying for phone calls.

Anon, yes. Good point. In return I received nothing but an idea for a blog post.

artiger said...

You don't have to tell me that life ain't fair.

My initial solution was no phone calls or other outside of office communication. You want to talk about the X Ray? Come to the office. Since when is a face-to-face encounter to discuss results/options a bad idea? Besides, we can then document it.

Skeptical Scalpel said...

Do you charge for these visits? How do the patients like your policy? It is possible to document phone calls.

artiger said...

If I provide a service, am I not entitled to bill for it? Patients don't seem to mind being charged if they are coming in, and it adds legitimacy to the documentation when it's face-to-face (in my opinion). Patients can claim a phone call was never made, but if they sign in for an office visit, it's hard to deny it.

Not that it should matter, but with 60-65% of my patients being Medicare and/or Medicaid, they don't really care.

artiger said...

As a follow up, I should mention that it is not my policy, it is just an idea I had. I'm employed, straight salary, so more office visits don't increase my income. I actually hate office visits unless they lead to a surgery.

Skeptical Scalpel said...

Of course you are allowed to bill for your services. I was talking about billing for phone calls which I think is uncommon for doctors to do. I assume your employer bills patients for their office visits and even for Medicare they must collect a co-pay. I don't think patients can claim they never called. Every phone provider keeps records of every call made.

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