Helpful Hints for Radiologists

[Gastrapathy]

@IJL Have you ever followed up and seen that turn out to be lymphoma?

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[scootad.]

Those examples cited by Winged Scapula are all too common. I say this as a radiologist, it’s quite embarrassing how low-quality some reports that go out are. It’s like some radiologists somewhere along the line during residency training had a complete lobotomy and forgot basic common sense medical management. I don’t understand it because we had to go through a year of internship not to mention pass the same med school standardized exams as every one else.

It’s like they use the radiology report solely as a way to avoid any legal responsibility and purposely throw in ambiguous recommendations that do nothing but confuse the referrer.

I know that sounds harsh but it’s the truth. And this is coming from a radiologist.

 

[IJL]

@IJL Have you ever followed up and seen that turn out to be lymphoma?

Definitely, usually in that case they'll have some big nodes too though. Normally I'll see misty mesentery in the setting of a patient with known lymphoma or another primary more commonly than as an incidental finding.

Depending on which study you read, mesenteric panniculitis is associated with malignancy anywhere from 5 - 50% of the time. I think it's probably on the lower end of that scale.

Mesenteric panniculitis: prevalence, clinicoradiological presentation and 5-year follow-up

I think it's reasonable to just get a follow up CT in 3 - 6 months just so make sure it goes away.

 

[Winged Scapula]

Oh ok. Yeah mammo is a little different because we act as quasi clinicians - but we aren't surgeons. I'll recommend biopsies, whether that's ultrasound/stereo/MRI guided or a surgical excisional biopsy, because that is mandated by birads.

I'm not talking about recommending biopsy.

That's appropriate and expected.

I'm talking about recommending specific surgical procedures without clinical experience and knowledge of relevant factors affecting surgical choice.

 

[Apollyon]

I'm not talking about recommending biopsy.

That's appropriate and expected.

I'm talking about recommending specific surgical procedures without clinical experience and knowledge of relevant factors affecting surgical choice.

I don't know why, but, I think I "like* every thing that you post. I don't know why, but it just "is". Maybe we just "click" on these things.

Thank Jesus for kismet!!

 

[Buzz Me]

Get a room, you two!

 

[Winged Scapula]

Get a room, you two!

Lol...

Isn’t this an improvement over the old days whern we used to argue all the time?

 

[Apollyon]

Lol...

Isn’t this an improvement over the old days whern we used to argue all the time?

But, see, now, I'm all old and whatnot, while you're still just hot!

 

[Winged Scapula]

But, see, now, I'm all old and whatnot, while you're still just hot!

I don't know about that, but rest assured I'm older as well!

 

[Apollyon]

I don't know about that, but rest assured I'm older as well!

Come on - long haired, pretty, blonde, surgeon, rolling up in the Benz, in stiletto Jimmy Choos? That's, like, a movie scene come true!! It's "I see it, but I can't believe I'm this lucky!"

 

[Buzz Me]

Lol...

Isn’t this an improvement over the old days whern we used to argue all the time?

Indeed.

 

[deleted547339]

Come on - long haired, pretty, blonde, surgeon, rolling up in the Benz, in stiletto Jimmy Choos? That's, like, a movie scene come true!! It's "I see it, but I can't believe I'm this lucky!"

This is getting weird......

Lol.

 

[dynx]

here’s a new one on me:
“Column of air posterior mediastinum cannot rule out esophageal perforation”

Phone call:
You mean the perfectly cylindrical column?
-yeah
It’s a balloon pump.
-what?
Nevermind. Just document “notifies a real physician”

 

[vhawk]

here’s a new one on me:
“Column of air posterior mediastinum cannot rule out esophageal perforation”

Phone call:
You mean the perfectly cylindrical column?
-yeah
It’s a balloon pump.
-what?
Nevermind. Just document “notifies a real physician”

Werent they worried where the aorta had gone

 

[OrthoTraumaMD]

Dear surgery colleagues,

Budding radiologist here (currently a resident). I hope to hear some of your pet peeves regarding radiology reports.

Are there any findings that we frequently omit, which require you to call or visit the reading room for elaboration? Are there impressions that we frequently overcall? (... or should never call, as they're clinical diagnoses)

I'm always working on improving the clinical relevance of my reads, but of course don't want to put my colleagues in a tough spot if I come down too hard on something.

Thanks!

For god’s sake, please stop “measuring” fracture displacement on xrays. It is worthless, as half the time it doesn’t matter, and the other half the time it isn’t done correctly. It only annoys us because we have to click and delete these annotations so we can see what we need to see.


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[deleted859535]

here’s a new one on me:
“Column of air posterior mediastinum cannot rule out esophageal perforation”

Phone call:
You mean the perfectly cylindrical column?
-yeah
It’s a balloon pump.
-what?
Nevermind. Just document “notifies a real physician”

Whoa. I guess we... all have our days?

 

[Cognovi]

For god’s sake, please stop “measuring” fracture displacement on xrays. It is worthless, as half the time it doesn’t matter, and the other half the time it isn’t done correctly. It only annoys us because we have to click and delete these annotations so we can see what we need to see.


Sent from my iPhone using SDN mobile

When does it matter? How is it done correctly?

 

[OrthoTraumaMD]

When does it matter? How is it done correctly?

Depends on the fracture, but most of the time we do not really care about the amount of displacement unless it is something extremely specific, when we are looking for things like clavicle shortening, or symphyseal separation in pelvic fractures. But the nuances are so complex that the measurements that radiologists make are not the correct ones anyway. And in terms of doing it correctly, it again depends on the fractured bone, its pattern, etc. I would say, don’t do it at all if you are a radiologist. What is useful is measuring abscess sizes on CT scans, the sizes of soft tissue lesions on MRIs, etc. Fractures? Not useful.


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[HighPriest]

Nasal bone fractures, too. In fact, I wish people would stop ordering scans for isolated nasal fractures. If you think the face is crunched, so be it. If you think it's just a nose, a CT is way too much and a soft tissue film is...well, worthless. Especially since there really isn't any indication to reduce a nasal fracture unless it's causing breathing or cosmetic issues. I get so many consults for "patient with nasal fracture on x-ray," the scan is read as a fracture (which maybe it is or maybe it's just a suture line or maybe it's just the way the guy's nose is shaped), and the patient looks fine, he's not concerned, and he's breathing ok. Easy, billable appointment....but ultimately a waste of time.....though I realize this is more on the urgent care centers of the world than it is on radiologists.

Conversely, you'll have the completely destroyed nose that's really obvious even on an x-ray....in which case I wonder why we needed an x-ray to make the diagnosis.

 

[scootad.]

I'm a radiologist and unfortunately I read a high number of nasal bone/facial bone/skull x rays. Completely worthless. I think it's because pt population is indigent and Medicaid will only pay for x ray (at least initially). It's BS.

 

[VA Hopeful Dr]

Nasal bone fractures, too. In fact, I wish people would stop ordering scans for isolated nasal fractures. If you think the face is crunched, so be it. If you think it's just a nose, a CT is way too much and a soft tissue film is...well, worthless. Especially since there really isn't any indication to reduce a nasal fracture unless it's causing breathing or cosmetic issues. I get so many consults for "patient with nasal fracture on x-ray," the scan is read as a fracture (which maybe it is or maybe it's just a suture line or maybe it's just the way the guy's nose is shaped), and the patient looks fine, he's not concerned, and he's breathing ok. Easy, billable appointment....but ultimately a waste of time.....though I realize this is more on the urgent care centers of the world than it is on radiologists.

Conversely, you'll have the completely destroyed nose that's really obvious even on an x-ray....in which case I wonder why we needed an x-ray to make the diagnosis.

As a guy who used to work urgent care, I get it. When I first started I didn't refer those. Got lots of patient complaints about it so now everyone with a nasal fracture gets sent to you. Just sprinkle some Holy Saline on it to bless it. That's all they really want anyway.

 

[HighPriest]

As a guy who used to work urgent care, I get it. When I first started I didn't refer those. Got lots of patient complaints about it so now everyone with a nasal fracture gets sent to you. Just sprinkle some Holy Saline on it to bless it. That's all they really want anyway.

It’s not the referral that bothers me so much. It’s the x-rays and CTs. I have no issue billing someone just to let them know that they don’t need anything done.

 

[HighPriest]

I'm a radiologist and unfortunately I read a high number of nasal bone/facial bone/skull x rays. Completely worthless. I think it's because pt population is indigent and Medicaid will only pay for x ray (at least initially). It's BS.

That’s good to know, and perhaps explains some of them. But at the same time, if there’s no indication of a facial fracture other than a broken nose, don’t even get the x-ray.

 

[VA Hopeful Dr]

It’s not the referral that bothers me so much. It’s the x-rays and CTs. I have no issue billing someone just to let them know that they don’t need anything done.

Same thing, although admittedly I don't order plain films for that. But patients want that CT scan because they know so-and-so who broke their nose and got one.

 

[HighPriest]

Same thing, although admittedly I don't order plain films for that. But patients want that CT scan because they know so-and-so who broke their nose and got one.

No offense, but "the patient wanted it" is a dumb reason to order a $1000 scan if you don't think it's indicated. I understand the pressure. I get patients all the time who want to dictate how I should care for them, but I try not to do unnecessary testing when it's not indicated. I get patients who come in with migraine headache who know "so-and-so" had sinus surgery and their headache got better, but if they're not a candidate for surgery I don't operate on them.

If the patient wants a second opinion from a plastic surgeon or an ENT, I get it.

 

[VA Hopeful Dr]

No offense, but "the patient wanted it" is a dumb reason to order a $1000 scan if you don't think it's indicated. I understand the pressure. I get patients all the time who want to dictate how I should care for them, but I try not to do unnecessary testing when it's not indicated. I get patients who come in with migraine headache who know "so-and-so" had sinus surgery and their headache got better, but if they're not a candidate for surgery I don't operate on them.

If the patient wants a second opinion from a plastic surgeon or an ENT, I get it.

Having lost 2 jobs over the years for not doing it, I really don't care. I make one good faith attempt to dissuade them, but if they want the test they can have an order for one. If its something acutely harmful, I won't budge (narcotics being the main one) but if they are insistent on a stupid lab test or imaging fine. I'm tired of getting new jobs.

 

[HighPriest]

Having lost 2 jobs over the years for not doing it, I really don't care. I make one good faith attempt to dissuade them, but if they want the test they can have an order for one. If its something acutely harmful, I won't budge (narcotics being the main one) but if they are insistent on a stupid lab test or imaging fine. I'm tired of getting new jobs.

redacting this because it's irrelevant to the conversation.

 

[scootad.]

Not to butt into the above discussion, but I can totally see a scenario where a doctor gets cut from a practice for not doing things the way "its always been done," even if its unethical. There's a lot of shady practices out there, where people are encouraged to order inappropriate tests for $$ reasons. Ethical doctors (except in certain sheltered environments, like academics, VA, kaiser), have lost control of medicine, to a certain extent.

 

[HighPriest]

Not to butt into the above discussion, but I can totally see a scenario where a doctor gets cut from a practice for not doing things the way "its always been done," even if its unethical. There's a lot of shady practices out there, where people are encouraged to order inappropriate tests for $$ reasons. Ethical doctors (except in certain sheltered environments, like academics, VA, kaiser), have lost control of medicine, to a certain extent.

I get that too, although if you're working an ER, is it the hospital firing you, or is it your multidoc group? And twice? In a row? I've definitely taken some heat in the past for doing what I thought was right even though it was against the grain, and I've had to defend myself for doing it. And, either by luck or otherwise, I've always been able to make the case that what I did was the right thing to do. I've been fortunate. Personally, I couldn't work for a place that forced my hand like that. But that's me.

In either case, I do sympathize. You always have two options: find a better fit or just do something unethical because it's an unfair world. And, yeah, just getting a scan is the easy route to go when it's not -particularly- dangerous. But, you know, our healthcare system is a financial disaster. Not just because of CT scans, but it certainly doesn't help.

In any case, my purpose wasn't to get into anyone's backstory. My point is still the same. These scans are an unnecessary financial burden on the patient and the system, they add nothing to management, and order inappropriate tests because the patient wants them is dumb. It's unfortunate if that got someone fired, but it's still dumb.

 

[VA Hopeful Dr]

You got fired from two jobs for not ordering an inappropriate test on a patient? Or for missing something?

Antibiotics specifically.

Technically it was "patient satisfaction", but the second time this was in the process of happening I decided to run a little test. After I was told my satisfaction scores were terrible, I decided to just give patients their z-pack for their 3 hours of sore throat. I changed literally nothing else (my HTN/DM/ortho patient management was unchanged). 1 month later my satisfaction scores went from last in the group to right in the middle of the pack. I gave my notice the next day and shortly thereafter word reached me that the admin was pleased this worked out that way as they had started the process to terminate my contract and this saved them the trouble.

 

[VA Hopeful Dr]

I get that too, although if you're working an ER, is it the hospital firing you, or is it your multidoc group? And twice? In a row? I've definitely taken some heat in the past for doing what I thought was right even though it was against the grain, and I've had to defend myself for doing it. And, either by luck or otherwise, I've always been able to make the case that what I did was the right thing to do. I've been fortunate. Personally, I couldn't work for a place that forced my hand like that. But that's me.

In either case, I do sympathize. You always have two options: find a better fit or just do something unethical because it's an unfair world. And, yeah, just getting a scan is the easy route to go when it's not -particularly- dangerous. But, you know, our healthcare system is a financial disaster. Not just because of CT scans, but it certainly doesn't help.

In any case, my purpose wasn't to get into anyone's backstory. My point is still the same. These scans are an unnecessary financial burden on the patient and the system, they add nothing to management, and order inappropriate tests because the patient wants them is dumb. It's unfortunate if that got someone fired, but it's still dumb.

Not in a row. Between the 2 jobs I started my own practice. Did very well at it in fact which was nice, I actually had started to worry that I was a bad doctor given how many patients complained about me when I spent a year doing urgent care.

 

[HighPriest]

Antibiotics specifically.

Technically it was "patient satisfaction", but the second time this was in the process of happening I decided to run a little test. After I was told my satisfaction scores were terrible, I decided to just give patients their z-pack for their 3 hours of sore throat. I changed literally nothing else (my HTN/DM/ortho patient management was unchanged). 1 month later my satisfaction scores went from last in the group to right in the middle of the pack. I gave my notice the next day and shortly thereafter word reached me that the admin was pleased this worked out that way as they had started the process to terminate my contract and this saved them the trouble.

Yeah, that I can see. That's unfortunate. And basing patient care on satisfaction scores is also dumb, fact of life or not. They should manufacture a sugar pill look-alike for a z-pack. Call it something fancy, like sucrosillin.

Still, would it not be an option to tell them that you'd prefer to have the "specialist" determine exactly what kind of imaging is necessary, and that you'll put a referral in to make sure they're seen as soon as possible? I tell the PAs nearby to tell the patient's I'm pretty picky about my imaging, and that I like to make that call myself for nasal fractures.