Wednesday, December 21, 2016

M.D. = Makes Decisions (unless you're a radiologist)

1 This is a cat. This is a hemangioma.
2 This is most likely a cat. This is most likely a hemangioma
3 This is consistent with a cat. This is consistent with a hemangioma.
4 This is most likely a cat, but get a follow-up picture to make sure it wasn't a baby tiger all along. This is most likely a hemangioma. Recommend follow-up to document stability.
5 This is most likely consistent with a cat. This is most likely consistent with a hemangioma.
6 This is likely a cat, but can't exclude a tiger hiding behind it way in the distance. This is likely a hemangioma, but can't exclude malignancy, sarcoid, etc.
7 This is likely a cat. Why don't you take a look for yourself and stop bothering me? This is likely a hemangioma. Recommend clinical correlation.
8 This is likely a cat, but get a saliva sample and send it in for genetic analysis. Better yet, kill the cat and dissect it. This is likely a hemangioma. Recommend biopsy. Open biopsy may be required.

In the real world (with the cat), anything other than statement #1 will get you laughed at. In radiology, statement #1 is rare. Instead we teach our residents and fellows, by our own weak examples, to be as non-declarative as possible.

Statements #2 and #3 are as declarative as most radiologists get. "I said most likely. What more do you want from me?!"

Statement #4 just passes the buck to the next radiologist.

Statement #5 combines 2 mild hedge words to produce one super-hedgy sentence.

Statement #6 is the reason Bayes rolls in his grave every time a radiologist signs a report.

Statement #7 is basically saying, "Thanks for the money suckers! This report was useless." We have access to so much patient data these days that it baffles me to see this in reports. Of course, this doesn't apply to cases where we're reading in isolation and when the only history we get from referrings is "pain," or some random ICD code. This negligent absence of data in a requisition borders on (is?) malpractice. I've seen it in imaging referrals my family members get from their doctors and it aggravates me to no end.

Statement #8, I don't even... For a cat/hemangioma?

Look, sometimes we have to hedge. Sometimes we are no better than Plato's cave captives, squinting at shadows with no idea of what's behind us. We know that two or more widely disparate entities can have identical imaging features. But when you know something can only be one thing, just say so. Save the patient some anxiety. And, save the rest of us some money by reducing unnecessary imaging.

What are some of your favorite radiology hedges?


  1. Good post. I'd like to share two of my pet peeves (i realize they are not really hedges but for some reason come to mind after reading this post).
    1. Redundant imaging: when either the radiologist recommends or the clinician orders two studies (usually a CT followed by MR) which yield the same (and no additional) information. For example: HCC diagnosed on CT, with subsequent MRI performed one week after the CT to "confirm HCC".
    2. Radiologist recommending a subspecialty consult in their impression. For example: Renal cell carcinoma. Recommend urology consultation. If the ordering provider does not know which sub-specialist to refer to based on the organ system involved they should not be taking care of patients

    1. Agree on both, Ryan.

      Regarding #1, what we see in MSK is CT CAP, followed by CT T-L spine and CT hip. The question then becomes, do you cancel the spine and hip CT and hope the person reading the CAP will comment on the spine and hip? Do you do the CAP and recon spines and hip to be read by MSK/Neuro, and is that legit from a billing perspective? Or, do you just do as you're told and expose the patient to radiation twice and give separate reads? I lean on the side of calling the referrings and asking them to cancel the spine/hip.

      Regarding #2, here ortho has asked us to recommend ortho consult when we see a bone at increased risk for fracture. This is in response to the rare cases where a case fell through the cracks.


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