tag:blogger.com,1999:blog-4968787219619380438.post8508156522360142471..comments2023-09-21T04:02:29.457-04:00Comments on Skeptical Scalpel: Vague radiology reports: Can anything be done?Skeptical Scalpelhttp://www.blogger.com/profile/13206922456661320751noreply@blogger.comBlogger46125tag:blogger.com,1999:blog-4968787219619380438.post-40582853612549677152019-11-15T07:52:42.875-05:002019-11-15T07:52:42.875-05:00Anonymous at 3:26 PM, thank you for your comments....Anonymous at 3:26 PM, thank you for your comments. Most doctors would agree with you that the electronic medical record is inadequate. Important information is obscured by the sheer volume of extraneous material and the difficulty in navigating through the many screens. It would be nice if a short summary could be provided for patients and physicians alike. Unfortunately, I don't think it's going to happen as long as physicians are being paid by the word.<br /><br />Anonymous at 5:03 PM, thank you as well. You also highlight the failure of the current electronic medical record software to facilitate communication among clinicians. Back in the day, a progress note was the way to let other clinicians know what you were thinking when you wrote it. Now there's a contest to see who can write the longest progress note. My observation is that the longer the progress note is, the less useful information it contains. I do agree that ordering physicians should give radiologists some idea of what they are looking for when they order a study.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-50107374325306016242019-11-14T17:03:35.036-05:002019-11-14T17:03:35.036-05:00Your comment about lack of communication is correc...Your comment about lack of communication is correct. There is an ongoing misunderstanding of the process of diagnosis in radiology. Many, sadly, think the imaging revels all like a labelled map, and there is no need to give any clinical context when ordering a study (see comments earlier on the thread). Many get their clerk to order studies, who have no idea why the scan is being requested.<br /><br />This misunderstanding of diagnostics (and the basic principals of pretest probability which are relevant to any scientific test) is typically followed by annoyance with the sadly predictable uncertainty expressed in the report.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-1031246340070117312019-11-14T15:26:24.884-05:002019-11-14T15:26:24.884-05:00Although this is an old post, I'd like to chim...Although this is an old post, I'd like to chime in with the perspective of a patient. Thank you, Scalpel, for your fascinating blog. As a middle-aged person who never had surgery at all until this year, when I've had five surgeries in six months, your blog has given some great information on things I've wondered about in the field of medicine.<br /><br />During the many scans I've had recently, I've been surprised to learn that radiology technicians and radiologists don't seem to have any background on my medical condition or previous surgeries, but make their conclusions without it. I would assume they would need that info to be helpful in the diagnostic process.<br /><br />I recently had an ultrasound as a follow-up after surgery to repair my ureter. The repair was done by re-implanting the ureter with the bladder flap technique. On the website of my hospital, I'm able to read the radiologist's report. It was a little alarming to read (I'm of course paraphrasing) that they noticed a mass on or near my bladder which they guessed might be a hematoma. I figured that the "mass" might be the bladder flap but it was still troubling until I was able to contact my doctor and he did confirm that the newly-made flap was what they were seeing and he reassured me that there was no "mass".<br /><br />I'm glad that my hospital makes those reports available to me but I could have done with a disclaimer as to how much "spitballing" was likely to be in those reports. I agree with some of the comments above: why wouldn't the doctor include that sort of pertinent information, for the benefit of radiology? Alternatively, why don't radiology techs or the radiologists look into a patient's history?<br /><br />Is there any sort of short summary of a patient's chart/history that could be quickly read or is it a matter of digging through a mountain of info? If medical professionals don't have the time to gather important information that could be crucial to a diagnosis, then the whole system needs a major over-haul. After my recent medical experiences, the thing that strikes me is the need for better communication all throughout the system. It seems like there could be a specialty within the medical field in which people just oversee the relaying of information or track patients individually as they navigate their various tests, procedures and surgeries.<br /><br />Thanks for letting me add my two cents and thanks to all the people who choose medicine as a career, I'm amazed to see the burdens you accept, on a daily basis, for the benefit of others.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-30381259415587354832017-12-01T11:05:05.266-05:002017-12-01T11:05:05.266-05:00Anon, thank you for your thoughtful comments.
You...Anon, thank you for your thoughtful comments. <br />You made a number of good points. It's interesting that you can't find much about what we want on radiology reports. I had never considered that. Maybe it's a good idea for a research paper.<br /><br />I've written a few posts about radiology. Search my blog for them if you have time. Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-32834917198480694322017-12-01T10:04:43.040-05:002017-12-01T10:04:43.040-05:00I figure I'll put in my two cents worth. Full ...I figure I'll put in my two cents worth. Full disclosure up front, I am applying to radiology residency this year so am 1) limited in experience and 2) of course going to be biased toward defending my chosen path (as is common among all in medicine)<br /><br />Part of the issue in radiology is simply the demand of the volume of images a radiologist is required to read. I have been with many radiologists that would love to have the time to dig into the history or even "gasp" go see the patient for themselves (admittedly this is not as common a desire). However, I have seen attending radiologists read hundreds of studies in a day that include CT and MRI in addition to plain films. They simply don't have extra time. This is why history and pertinent information is so important to be given when imaging is ordered (I have seen numerous that just say "pain" or have seen a few that are just made up because the referring physician didn't seem to think it was important). I feel this is where the application of machine learning/deep learning algorithms will benefit radiology. By automating a lot of processes, like finding and measuring lung nodules (which is enjoyed by no one) or even somehow digging through reports and giving relevant information for the given indication. This may free up radiologists to spend more time on complicated cases and provide more clinically informed/relevant reports.<br /><br />I think it is also important to note that radiologists do what one radiologist referred to as a "legal check". Which was after looking at the reason for the exam they have to look at the complete study and make sure to not miss even a subtle finding in an area not related to the given indication. Because, in the end, they are responsible for anything and everything in the provided imaging which is why this information is included in the report regardless if it is relevant or not. Though, it seems a lot will bury the non-relevant information in the body of the report and try to stick with pertinent findings in the impression to help the referring physician who understandably doesn't care about random findings that have no bearing on the reason they ordered the study.<br /><br />It seems to me hedging in reports stems from a few things. One being medical legal reasons (occurs in all aspects of medicine even though it isn't always right or of benefit for the patient). Another being that the radiologist has been chewed out and belittled too many times by referring physicians for "diagnosing their patient". It appears to me (being on the sidelines still and the observing medical student) that a lot of radiologists simply give up and stop doing things like having discussions with other physicians about appropriate imaging because the referring surgeon/ER physician/whoever isn't receptive and belittles them or simply because they don't have the time. Also, hedging happens because there is a lot of overlap in imaging findings and without proper history or labs or further imaging it's impossible to differentiate. And without adequate time to search the charts or see the patient, the dreaded "Correlate clinically" is written and the radiologist moves on to the next on the never ending list of studies.<br /><br />Just an F.Y.I, I made it to this blog post because of trying to find information on exactly what referring physicians want in reports (it's not easy information to find and varies greatly, physicians are not always easy to please).Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-4236786862164271202017-03-12T11:54:00.954-04:002017-03-12T11:54:00.954-04:00Sorry for the delayed response. I was out of the c...Sorry for the delayed response. I was out of the country. I think you are doing the right thing by waiting. I hope it turns out OK.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-62448409149807192692017-03-09T01:24:04.438-05:002017-03-09T01:24:04.438-05:00Believe it or not I just read this whole thread be...Believe it or not I just read this whole thread because I, a layperson (ok I have a science undergrad but am an engineer now) am trying to figure out what further tests we should do, on my puppy, who has a leg bruise or a bone infection. This thread is helpful as I'm always trying to figure out, when I hear radiology reports about me or my kids, if "the thing seen" is a "likely to be X" or a "could be X" or a "we can't entirely rule X out." Facing the reality that even patients, not just clinicians and radiologists, are also in the complex matrix of figure out when to further test and when to wait.<br /><br />I've decided to wait, in my puppy, as his symptoms are improving (he's walking better....probably wouldn't be if it were an infection, so hopefully just trauma and inflammation.) As Mayoman said very nicely, often time, to see which way symptoms trend, is very telling. Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-35858578016859042012016-11-26T13:55:38.118-05:002016-11-26T13:55:38.118-05:00Mayoman, I appreciate your points but call your at...Mayoman, I appreciate your points but call your attention to this piece from the JACR entitled "Do not hedge when there is certainty." http://www.jacr.org/article/S1546-1440(16)30803-1/abstractSkeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-63691331318010017852016-11-24T00:25:36.262-05:002016-11-24T00:25:36.262-05:00Thanks for the reply on an old thread, but serious...Thanks for the reply on an old thread, but seriously, why bother being pedantic about the quotes. It was clear from the content that they were paraphrased quotes, intended to relay the essence of previous comments in a conversational style, so why bother pretending to be confused about where I sourced them? To be pedantic about it, as you said yourself, "Quotes are usually statements that are cited word for word". Correct, "usually", but not always. Conversational paraphrasing is an accepted exception to this. This was a pointless attempt to nitpick a valid literary style, why bother?<br /><br />As regards the point about pre-test probability, it is crucial to this whole discussion. There is no such thing as a test that tells you if a certain diagnosis is certain or not. Sorry, medicine is not that easy. You feel removing a normal appendix should only happen 4-5% of the time, and infer that unclear radiology reports increase this rate. It makes the assumption that reading a CT scan is simply a case of looking at the screen and announcing if there is appendicitis or not. You said it yourself "just tell me what you see". Guess what? Malignancy, trauma, infection, inflammation can all look identical. 100% identical. There are case series for trainees that illustrate this. The screen doesn't turn yellow for appendicitis, red for trauma, etc. <br />As somebody previously commented, they wouldn't diagnose appendicitis based on a blood test. True, but would you operate without knowing the white cell count (if it was easily available), the patient's temperature, etc? I removed over 100 appendixes, and used every strand of info I could get to help my decision to operate, including the greatest test for unclear cases (if at all possible), time. None of these tests diagnose appendicitis, but they all add a little to the overall clinical picture, as do the CT/MRI/US findings. You complained in a previous report that a radiologist can report mild appendiceal stranding, and potter off while you have to make a 3am call whether or not to operate. The implication (which is basically the thrust of this entire blog) was that the radiologist let you down, they should have called it for you. Sorry, it doesn't work that way, if there was stranding, there was stranding, it can mean many things, including appendicitis. Medicine is hard. Deal with it. You want a definite call on a case, yet you wondering what difference a clinical history made to radiologists. Which is why I advised you to try and get a better grasp of pretest probability.<br /><br />You say that you get on well with radiologists, yet some of your postings openly insult the profession. Statements such as radiologists are just not good clinicians, they never put a hand on a patient, etc. Most of my group, including myself, combine diagnostics with procedures. Outpatients, admissions, ward rounds, and yes, stethoscopes, used as competently as most surgeons. I have also being in the difficult position of reading scans, and deciding whether or not I just preform a difficult intervention (often at times such as 3am, just like you), based on combined image findings, lab results, and clinical findings. No one piece of the puzzle provides the answer, and the decision to intervene occasionally turns out to be unwise. <br /><br />Applying best practice scientific method (including telling the reporting radiologist what is known so far in the case - this is basic common sense), while accepting that some small degree of uncertainty will always remain, is the essence of diagnostic medicine.Mayomannoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-70232673275642740802016-11-23T18:35:04.911-05:002016-11-23T18:35:04.911-05:00Mayoman, thanks for commenting. I don't know w...Mayoman, thanks for commenting. I don't know where you got the statements you quoted in your comment. Quotes are usually statements that are cited word for word. No one, myself or commenter, said what you quoted.<br /><br />Comments on this post seem to be going along the lines of clinicians (those who actively take care of patients) and radiologists. <br /><br />I happen to know a few things about positive and negative predictive values and likelihood ratios. They are attempts to quantify the unquantifiable, particularly when it comes to something as subjective as a reading and the pretest probability is a guess. If the pretest probability is 60% and the CT reading makes it 75%, that's still not much help. Removing a normal appendix should not occur more than 4% or 5% of the time. <br /><br />No one said radiologists aren't clinicians because they don't wear stethoscoipes. I simply said I had never seen a radiologist with a stethoscope. That is still the case.<br /><br />No one said tell me if it's appendicitis 100% yes or no either. If a radiologist doesn't know, why not just say, "I don't know" instead of using vague CYA terms? I have told patients many times that I don't know what's wrong with them, but that I would keep trying to find out.<br /><br />You ignored the many favorable things I said about radiologists in the post and in the comments. That's OK. You can say whatever you want. <br /><br />I worked with many fine radiologists over the years and the helped me countless times.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-73451140995599584362016-11-23T17:26:40.698-05:002016-11-23T17:26:40.698-05:00Old thread sure, but I'd like to add my two ce...Old thread sure, but I'd like to add my two cents, there are a lot of silly statements in this thread:<br /><br />1) "Have radiologist read studies without clinical information". OK, by that logic, you should examine and diagnose patients without taking any history. This isn't a game, patients get substandard treatment all the time due to lack of basic communication skills among doctors. If you haven't heard of positive predictive value and pretest probability, I suggest you read up on it, and stop ordering expensive studies until you get up to speed.<br /><br />2) "Radiologists aren't clinicians because they don't wear a stethoscope". Again, a moronic statement, there are many types of doctor, some with wide generalist skills like internal medicine or family practice, others with a very specalized and therefore limited set of skills, like radiologists or surgeons. And some would argue that sonography is a massive upgrade on auscultation.<br /><br />3) "Why won't they just tell me if it's appendicitis 100% yes or no". You don't really understand how scientific tests work, do you? Tell me if you find a 100% sensitive and specific test, so I can go buy shares in the company.Mayomannoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-81944811780820983972014-07-24T14:00:45.772-04:002014-07-24T14:00:45.772-04:00Kat, most radiologists would not give a definitive...Kat, most radiologists would not give a definitive diagnosis such as adenoma, which must be made by a pathologist. It could be a carcinoma. To call it an adenoma would be potentially misleading.<br /><br />You are correct that a normal parathyroid is measure in mm not cm. Even a parathyroid tumor would rarely grow to 4 x 3 cm.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-42859026559283304672014-07-24T00:17:23.613-04:002014-07-24T00:17:23.613-04:00I want to know how a radiologist can say:
FINDING...I want to know how a radiologist can say:<br /><br />FINDINGS: An enhancing 4 x 3 cm enhancing focus posterior to the right<br />lobe of the thyroid is suggestive of an adenoma (series 10 image 41). A<br />venous structure is noted to extend inferiorly from the lesion.<br /><br />Dimensions were given. This is suggestive of an adenoma. So if it's not and adenoma, what is it? Parathyroids are tiny and not easily detectable. Kathttps://www.blogger.com/profile/08351803058890797224noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-52110298696533694512013-08-25T10:51:08.890-04:002013-08-25T10:51:08.890-04:00Thanks for commeneting. I think most radiologists ...Thanks for commeneting. I think most radiologists do care about what they are looking at. I have writtennotes in charts saying I disagreed with a radiologist's report. It happens.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-72797638970077303992013-08-25T07:00:22.044-04:002013-08-25T07:00:22.044-04:00My oppion is radiologists dont really care about w...My oppion is radiologists dont really care about what they are looking at, to rushed to report what they <br />See and have no one to answer to when extremely vague reports are an issue. I dont see doctors <br />Writing reports and challenging what is written by radiologists or not written. If radiologists have the<br />Final say then the law needs to be more firm about how films are read.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-34097741640377142862013-07-06T21:44:12.505-04:002013-07-06T21:44:12.505-04:00No sure what that means?
No sure what that means?<br />Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-68866821006169445312013-07-06T13:25:08.637-04:002013-07-06T13:25:08.637-04:00I'd say that's a significant number of cha...I'd say that's a significant number of changed reports. You might have a quality issue.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-62583420268032489762013-07-06T04:40:51.718-04:002013-07-06T04:40:51.718-04:00I think 5 in the same year. Possibly more.I think 5 in the same year. Possibly more.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-32313383282483752152013-07-05T15:34:30.766-04:002013-07-05T15:34:30.766-04:00Depends on the time frame, but 10 in one or two ye...Depends on the time frame, but 10 in one or two years would be very unusual.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-83926596995896402992013-07-05T15:20:00.800-04:002013-07-05T15:20:00.800-04:00Would it be highly unusual to find 10 changed radi...Would it be highly unusual to find 10 changed radiology reports in you records.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-84292158547848070682013-04-26T03:23:06.187-04:002013-04-26T03:23:06.187-04:00I was looking for something about radiology progra...I was looking for something about radiology programs. Glad to come across this post. Good job.<br />radiology programs in chicagohttp://www.northwesterncollege.edu/career-programs/health-care/radiologic-technologynoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-28778307615877617592013-02-15T11:28:03.611-05:002013-02-15T11:28:03.611-05:00I'm not sure what your questions are about but...I'm not sure what your questions are about but I'll try to answer.<br /><br />Reports can be amended as long as the change is dated and timed. This is automatic with electronic records. The original report is unchanged. The amended text goes in as an addendum at the bottom of the original.<br /><br />It's not necessarily defensive medicine. The radiologist could have re-reviewed the images or asked a colleague to look at them. Since the original is still there, there is no way to change it to be more defensive.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-68582149720404753552013-02-14T13:25:50.190-05:002013-02-14T13:25:50.190-05:00Why would radiology reports be amended to look lik...Why would radiology reports be amended to look like original reports?What happens to the original report? Defensive medicine?Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-69914415543916487282012-12-23T20:46:18.317-05:002012-12-23T20:46:18.317-05:00Yes, I would prefer a timely, unambiguous reading ...Yes, I would prefer a timely, unambiguous reading by a board- certified radiologist who I could go over the images with even at 2 am. Unfortunately, that is not always possible.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-7990865713969201362012-12-23T17:58:42.229-05:002012-12-23T17:58:42.229-05:00Just a message to Skeptical Scalpel - If ever you ...Just a message to Skeptical Scalpel - If ever you required any form of imaging for yourself or your family member for a complaint, I doubt very much you would be relying on your own interpretation skills of it as a surgeon. If you want to interpret images - get board certified first! Anonymousnoreply@blogger.com