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.

Radiologists have an identity crisis

Here's a question that has been debated for several years: Should radiologists talk to patients about their imaging results? Citing several issues, I came down solidly on the "No" side in a 2014 blog post which you can read here.

Two major radiology organizations have committees looking into the concept, and a New York Times article said, "they hope to make their case [for it] by demonstrating how some radiologists have successfully managed to communicate with patients and by letting radiologists know this is something patients want."

However, a recent paper presented at the annual meeting of the American College of Radiology raised a new issue.

Apparently patients need more basic information before talking to radiologists—namely what exactly is a radiologist and what does a radiologist do?

A group from the University of Virginia surveyed patients waiting to have radiologic studies performed and came up with some remarkable results. Of 477 patients surveyed, only 175 (36.7%) knew that a radiologist is a doctor, and 248 (52%) knew that radiologists interpret images.

Based on those findings, the investigators developed an educational program of PowerPoint slides which was shown to a new series of 333 patients in the waiting room. When surveyed after viewing it, 156 patients (47.7%) said they were aware that a radiologist is a doctor, and 206 (62.2%) knew that radiologists interpret images.

Both responses were significantly better after the educational presentation, but still, less than 50% of patients identified radiologists as doctors. Maybe the problem was the PowerPoint. Maybe radiologists need to wear scrubs or drape stethoscopes around their necks.

This is only a small study from one institution. Nevertheless before taking the big step of talking with patients, it suggests radiologists need to do a better job of explaining who they are and what they do.

We surgeons think we have an image problem when people say to us, "Oh, are you just a general surgeon?" They don’t know what we do, but at least they know we are physicians.

Irrational fear of CT scans in appendicitis

By Skeptical Scalpel and Saurabh Jha*

Simple appendicitis cannot be distinguished from complicated appendicitis by clinical examination and laboratory findings say Finnish investigators. They looked at data from their randomized prospective trial of antibiotics vs. surgery for treatment of appendicitis and concluded that only CT scans could reliably differentiate the two entities.

The study involved adult patients from 18 to 60 years old; 368 of whom had uncomplicated acute appendicitis and 337 had complicated appendicitis—appendicolith, perforation, or abscess.

Duration of symptoms, C-reactive protein, white blood cell count, and temperature were significantly different between simple and complicated appendicitis patients. However substantial overlap of values meant they were not helpful in predicting the presence of complicated appendicitis.

Receiver operating curves for C-reactive protein and temperature areas under the curve do not exceed 0.77. Combining these parameters did not improve accuracy.

The paper concluded that CT scanning is essential in diagnosing acute appendicitis and identifying simple and complicated cases.

A companion study by many of the same authors looked at 1321 patients who presented with clinical and laboratory findings of possible appendicitis. Since their protocol called for confirmation of the diagnosis, all patients underwent CT scans, and 351 (27%) did not have appendicitis.

So you want to be a Radiologist

A student writes, I've been following some of your posts and noticed some of the comments by others mentioning that radiology residencies/jobs are drying up and even face the possibility of disappearing completely. Could you explain why? I am currently a senior pre-medical student who's taken a recent liking to radiology after following a few radiologists in a hospital, so I would just like to get some input.”

A colleague, Dr. Saurabh Jha, an Assistant Professor of Radiology at the Hospital of the University of Pennsylvania, has graciously agreed to respond. He can be followed on Twitter @RogueRad.

Should I go into radiology?

I used to be a surgical resident in the UK. One day, I was a little dispirited during a brutal call, and my senior resident asked “do you love surgery?”

“I like surgery,” I replied.

“If you don’t love surgery, love it unconditionally I mean – like loving your child – you will be unhappy.” He warned.

I really liked surgery. I like radiology. I’m happy as a radiologist. Radiology fits my temperament. You don’t have to love radiology like one has to love surgery, but you have to like it. It helps if you like it a lot.

The worst reasons to go in to radiology are to make lots of money and to avoid patients. The days of radiologists making $500 K + 12 weeks of vacation after reading 20,000 studies a year are over. Radiologists doing interventional, ultrasound, mammography and fluoroscopy (such as barium enemas) must speak to patients, and speak well.

Radiology is a tech-heavy field. If you’re excited by technology, you will like it. Radiologists are leading healthcare in IT. If you have an interest in health IT, then some programs will integrate informatics with your training.

Residency involves substantial reading. You have to master anatomy, radiological pathology, and physics, as well as have a decent knowledge of clinical medicine. Prepare for 20-30 hours of reading a week. Radiology is now 24/7. Calls are intense – 12 hour shifts are non-stop. But when you are off, you are off.

Believe it or not, international health – if you are into that – increasingly asks for radiologists. Although you won’t be parachuting in to Sierra Leone or quarantined in Fort Hood.

Will there be jobs when I graduate?

Should radiologists tell patients their test results?

Radiologists discussing test results with patients, a subject that has been lurking under the radar for a while, recently came to light because of an article in the New York Times. The idea is that patient anxiety while waiting to find out a test result could be alleviated by an immediate discussion with a radiologist.

That would be very nice, but there are potential problems, some of which are detailed in a post that appeared on the website of The Advisory Board and others in an editorial by radiologist Saurabh Jha accompanying a paper on the subject..

In the Times, Dr. Christopher Beaulieu, chief of musculoskeletal imaging at Stanford, said, “[T]he radiologist may be capable of transmitting the information but the obvious next question for the patient is, ‘What do I do now?’ which, as nontreating physicians, radiologists are not trained to answer.”

Is ultrasonography overrated? A radiologist thinks so

In response to an article in the New England Journal of Medicine that discussed whether bedside ultrasonography (US) should be taught to medical students, radiologist Dr. Saurabh Jha recommended that clinicians do a proper history and physical instead of point-of-care ultrasound.

His post appeared on the KevinMD website.

As if a radiologist advising doctors to do an H&P wasn't shocking enough, Dr. Jha then confessed that he thinks "ultrasound images look like a satellite picture of a snow blizzard."

He worried that rather than finding hidden pathology, indiscriminate use of US by inexperienced physicians will simply lead to more and more testing.

Even seasoned radiologists tend to overcall abnormalities on US said Dr. Jha. This leads to increased use of other imaging studies, most of which turn out to be normal. Using US to avoid the risks of ionizing radiation often results in patients having CT scans anyway.

In the comments section of the post, Dr. Jha emphasized that he was talking about situations where the pretest probability of finding something wrong is very low. Directed US based on clinical indications is obviously of value.

Emergency medicine physicians who

Photo via Dr. Ryan Radecki (@emlitofnote)

commented listed several instances which bedside US can be useful such as in identifying pericardial effusions and fluid or blood in the abdomen of trauma patients.

Ultrasound is clearly the test of choice for right upper quadrant abdominal pain. There is nothing better for identifying gallstones, but thickening of the gallbladder wall and fluid surrounding the gallbladder are best seen with US done in the radiology department.

Probing all body cavities with a transducer for no specific indications is another matter.

Is there still a role for a good history and physical examination in modern medicine? Yes.

Is US a useful test? Yes, in the proper context, it can be very helpful.

Should every medical student be taught how to do bedside US? I don't think so. A course is just the beginning. Learning how to perform US requires a lot of repetitions. Many medical specialists will never use it.

I agree with Dr. Jha that the time should be used to "Teach them to organize their thoughts coherently."

What's your opinion?

Note: These folks also tweeted the photo.@EM_Educator @MDaware @EBMGoneWild @choo_ek

Can you guess the diagnosis using this radiology report?

Here are some excerpts from a radiology report I received. I left out some portions that were not pertinent and I highlighted in bold some of the better parts. My comments are in brackets.

This was in reference to a CT scan of the abdomen for abdominal pain.

Free peritoneal air is present. Proximal small bowel loops are dilated to about 4 cm in diameter. In the lower abdomen and upper pelvis there is a region of edema and a change in caliber of the diameter of the bowel consistent with bowel obstruction. This edema also surrounds the sigmoid colon. There are diverticula and diverticulitis is a consideration. Perforated diverticulitis is also another consideration for the free air. There are some collections of air along the right side of the sigmoid colon which may be extraluminal or perhaps some prominent diverticula. A small abscess in this region is a consideration. There is diffuse edema in the lower omentum.

No abnormal masses are seen in the pelvis. No significant amount of free pelvic fluid is present. {Is there an insignificant amount of fluid?]

No appendicitis. No diverticulitis. No free air.[!]

IMPRESSION: Proximal small bowel obstruction. Questionable diverticulitis with questionable small abscess adjacent to the sigmoid colon. Pneumoperitoneum [“Pneumoperitoneum” means free air in the abdominal cavity.]

Is there diverticulitis? Is there free air? What the hell is going on?

So if you were the surgeon, what would you do?

At least the radiologist used the correct plural form of the word “diverticulum.” See my previous post on this topic.

Appendicitis: Accurate diagnosis or no radiation. You make the call.

Amid the mounting concern about radiation exposure and future increases in cancer rates comes a report from Washington State describing the benefits of imaging, particularly CT scanning, for the diagnosis of appendicitis.

The authors collected data from some 55 hospitals of all types and sizes over a six-year period for more than 19,300 patients older than age 15; 91% of patients underwent one or more imaging studies. There were 16,852 (87.2%) CT scans, 1160 (6.0%) ultrasounds and 108 MRIs (0.6%) with 1677 (8.7%) patients having no imaging.

If a patient had an imaging study, the rate of normal appendix removal was only 4.5% compared to 15.4% for those who were not imaged, p < 0.001. Stated another way, on multivariate analysis a patient who had no imaging was over 3 times more likely to have a normal appendix at surgery. Only 4.1% of those undergoing CT scan had a normal appendix compared to 10.4% of those who had only an ultrasound, p < 0.001.

The difference in the rate of normal appendix removal was true regardless of gender—men 3% with imaging vs. 10% without and women 6.9% vs. 24.7%, both statistically significant differences. In other words, nearly 1/4 of all women who were not imaged had a normal appendix at surgery.

Perforated appendicitis occurred in 15% of all patients, a figure that has remained constant over many years and has not been influenced by imaging.

The Washington appendicitis experience is probably generalizable because in most hospitals, CT scan is the preferred imaging modality over ultrasound, which is more operator-dependent, less accurate and less available during off hours than CT scan.

My personal experience is similar to that of the authors of the study. My rate of removal of a normal appendix when operating for the presumed diagnosis of appendicitis is 4.3% for my last 200 cases. Only 18 (9%) of my patients, all young males, had no imaging and just 1 had a normal appendix. CT scans were the only studies performed in 99% of my patients who were imaged.

I have previously written that patients and their families seem to prefer an accurate diagnosis over a theoretical slightly higher cancer risk 20 or 30 years later. The paper from Washington also confirms that a high accuracy rate of CT scanning for appendicitis is achievable outside of academic centers.

For many reasons, I can’t imagine the rate of CT scans for the diagnosis of patients with right lower quadrant pain decreasing. The accuracy of CT is no longer an issue. Most ED MDs are scanning everyone with right lower abdominal pain. They may tell you it’s because surgeons insist upon it, but whatever the reason, a lot of CT scans are being done. Another advantage of CT scanning is if the diagnosis is something other than appendicitis, the CT will very often reveal what is wrong with the patient. In a previous blog, I have mentioned before that it would be impractical to ask surgeons to examine every patient with abdominal pain, one of the more frequent complaints of patients presenting to emergency departments.

Face it, CT scanning for the diagnosis of appendicitis is here to stay. Whether implementation of protocols to lower the radiation dose of the devices will calm all the doomsday prophets remains to be seen.

[Thanks to Dr. Frederick Thurston Drake, lead author of the paper from Washington, for providing me with information not published.]

Vague radiology reports: Can anything be done?

Possible mild peri-appendiceal inflammation. So states a CT scan reading I received the other night.

Here’s another. The findings are concerning for appendicitis.

And another. The appendix is dilated and mildly thick walled with suggestion of mild surrounding inflammatory change, although there is air within the lumen. There is an appendicolith at the base of the cecum. The findings are suspicious for mild acute appendicitis. Clinical and laboratory correlation are recommended. [Digression: You can't diagnose appendicitis with lab tests.]

Even radiologists are questioning the way their colleagues dictate reports. From an editorial in the journal Applied Radiology: The report might say “there appears to be a nodule in the right lower lobe.” If you’re wrong, and there isn’t a nodule in the right lower lobe, you’re covered because you never actually said there was a nodule, only that there appeared to be a nodule, and we all know that nothing is ever as it appears.

Some Stanford researchers looked at radiology reports and found that the most frequent terms used to modify conclusions were probable, consistent with, consider, likely, suggestive, no definite evidence, suspicious, cannot exclude, not likely, maybe and possible. They surveyed radiologists and clinicians and found wide variations in what these words meant to each physician regarding the specifics of whether a hypothetical lesion should be biopsied.

An editorial in the journal Radiology scorned the use of the often-seen phrase if clinically indicated.

I could go on.

Do you know of similar examples of radiologic ambiguity?

Is there a solution to this problem?

A version of this post appeared on Sermo yesterday with interesting comments. About 2/3 of those who voted said there is no solution to the problem. Some commenters said the radiologists are just describing what they see.

A Radiologist’s Idea of a Definitive Report

Here is an excerpt from the text of a CT scan report I received today:

The appendix is dilated and mildly thick walled with mild surrounding induration [sic]. There is gas within the lumen, but there is also an appendicolith at the base of the appendix with a smaller appendicolith in the mid appendix. The findings are concerning for appendicitis. No other inflammatory changes are seen. There is no adenopathy or free fluid.

IMPRESSION:

The appendix is dilated and mildly thick walled with suggestion of mild surrounding inflammatory change, although there is air within the lumen. There is an appendicolith at the base of the cecum. The findings are suspicious for mild acute appendicitis. Clinical and laboratory correlation are recommended.

I think it's somewhat mild. Don't you?

As the old joke goes, what is the radiologist’s favorite plant? The “hedge.”