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Should your radiologist tell you the results of your scan?

11.27.14 // Linked, Medicine, Radiology

Probably not. But some interesting lines from Gina Kolata’s article in the NYTimes:

Dr. Christopher Beaulieu, chief of musculoskeletal imaging at Stanford:

At that point the 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.”

This issue here is not that radiologists aren’t “trained” in what happens next (in many cases, of course they are!)—it’s that radiologists don’t actually do what happens next. If you aren’t going to provide treatment, you probably don’t need to be offering patients their options, particularly if you aren’t privy to their history.

For now — with one big exception — how quickly a patient gets the results of a scan, including M.R.I.s, PETs, CTs or ultrasounds, can be idiosyncratic and depend on the particular doctor and the particular patient.

Yet patients want to hear from radiologists, the groups say. One admittedly unscientific indicator was patients’ comments to the American College of Radiology on Twitter. They said they did not want to wait for results and could not understand why a radiologist would tell a doctor their results but not them, said Dr. Geraldine McGinty, chairwoman of the group’s commission on economics.

Realistically, patients want their results quickly and probably don’t care who tells them. The main issue here is patient scheduling. It’s not fair to patients to have an MRI one day and then have an appointment with the ordering provider two weeks later. Many physician schedules are fully booked with routine follow-ups, leaving no room for add-ons when unexpected scan results come up. In some thoughtfully scheduled clinics, patients have a scan in the morning and are seen that afternoon. That’s ideal.

If a patient then still wanted to speak to a radiologist (leaving aside the issue of the non-reimbursable time spent), I think both the radiologists and the referring clinicians would be much happier having that happen in a context in which the definitive management discussion would happen immediately afterward and not in some yet-to-be-determined future appointment. If the patient finds out before the referring provider, then the system breaks down. And learning you have cancer only to be told you won’t be seen by the oncologist until three weeks later is also not therapeutic. We need to be more thoughtful in how patients are scheduled for follow-up—that’s the crux.

“The chance of your actually seeing a radiologist is almost zero,” said Steve Burrin, a physicist and retired vice president of The Aerospace Corporation. Mr. Burrin, 70, who has lung cancer and lives in Los Angeles, has so many scans — CT, M.R.I., PET — that he decided to take matters into his own hands. Now, he immediately asks for a copy of his scan and tries to understand it himself.

I do though think the current state of patient accessible information is problematic. More and more patients have access to their raw reports, which are written for a physician reader.1In many cases, the body of the report is actually geared for other radiologists and specialists and is confusing to most other physicians (which isn’t necessarily a good thing either) The information, terminology, and certain turns of phrase can be bewildering and frankly misleading to patients. If a patient report states there several “indeterminate renal hypodense lesions” which are “too small to characterize,” that sounds super mysterious. But they’re really just (essentially always) tiny cysts of no clinical consequence.

If the future is centered on more transparency and patient empowerment, it would probably be better if a patient-centered report was incorporated into the medical record with the salient points written in accessible language. This is similar to the approach used by WebMD and Medscape, which are owned by the same company, where there are pages on the same topic with one set of data shown to patients and another set to physicians.

Learning Radiology for Medical Students & Non-radiologists

12.05.13 // Medicine, Radiology

Most radiology books make for a terrible and overwhelming introduction to radiology for medical students or non-radiologists. The physics. The detail. The long lists of differentials and rare conditions. A clinician with limited time is best served with having a grasp of the different radiologic modalities, their limitations, and the proper exams to order to answer a particular clinical question. After all, clinicians—unlike radiologists—have the opportunity to correlate clinically.

Next, interpretation of plain films can be an essential skill. This is particularly true of chest x-rays in practice contexts where wait times are too long to guide clinical management. Surgeons of various types will find differing degrees of imaging knowledge to be relevant, particularly for operative planning.

Below is a brief list of high quality free online resources as well as a handful of excellent print books.

General introductory texts for medical students and non-radiologist physicians:

Learning Radiology: Recognizing the Basics is the best book geared for medical students (or non-radiologist physicians). A slightly faster read / good alternative would be Squire’s Fundamentals of Radiology, which was the de facto standard before Learning Radiology came around. Squire’s gives a very readable alternative but has fewer examples and is slightly less helpful in actually learning to interpret images yourself. It also costs more and hasn’t been updated in a while, so it’s a little less fresh (but not out of date). If you don’t want to buy anything, Herring’s companion website LearningRadiology is beloved, widely-utilized, and entirely free.

Learning how to interpret chest films yourself

Look no further than the very readable Felson’s Principles of Chest Roentgenology. The CXR aka chest x-ray is the most common radiologic study obtained by a country mile, and everyone should know how to do this. If you’ve ever worked with someone “who read all of their own films” but then couldn’t see what the radiologist was talking about, read this and you’ll have the context to do better. Actively evaluate the exam, and correlate the films you see in clinical practice with the reads you receive. The combination will help you more than simply opening up the study in the EMR and looking in its general direction for a big white blob somewhere. Pick a search pattern and stick to it. Use it every time. You can’t see what you aren’t searching for.

Free online resources

There are a seemingly limitless number of free online radiology resources, far far too many to even approach. For an example of an extensive list, see Radiology Education.

Here is my significantly briefer list of excellent general radiology resources for medical students, whether you’re interested in the pursuit of knowledge or the pursuit of a career in the field. Everyone has to start somewhere.

  • The Radiology Assistant is probably my favorite, very readable and concise.
  • Radiopaedia is the wikipedia of radiology. Articles are pretty terse, but when you see a finding or diagnosis and want to have an explanation, this is where to look (e.g. what the heck is “ground glass“?)
  • University of Virginia’s Introduction to Radiology online tutorial series is one of the best and even covers some more esoteric modalities (like cardiac MRI).
  • CaseStacks has lots of great paid cases to learn bread and butter for a decent price (and 15% off with code benwhite) but they also have some great free anatomy content.
  • Learning Radiology is a massive resource with lots of cases. The design is somewhat overwhelming and cluttered, but don’t let that discourage you.
  • Lieberman’s eRadiology is another nice, big, well-organized resource, including a lot of lectures, powerpoints, cases, imaging workup algorithms, etc.
  • HeadNeckBrainSpine was easily the best resource for learning neuroanatomy, but it uses Flash, which makes it unusable on most university computers.
  • And my final far-reaching inclusion is Radiology Resources for Medical Students, which is also solid but requires a bit too much clicking to get around the lessons.

Keep your eyes open

For anyone with plans to enter radiology as a career, know that you will almost certainly learn more radiology in your first two weeks of training than you could hope to amass during medical school or internship. Knock yourself out, but don’t forget this is your last chance to be exposed to the unadulterated breadth of clinical medicine.

If you have a book fund and want some good reading geared toward beginning radiologists, then you might find this post helpful.

If you’re a specialist (pulmonologist, urologist, etc) and are looking for more focused resources divided by section or modality, then see this compilation.

Applying to Radiology

08.24.13 // Medicine, Radiology

Applying for residency is anxiogenic. That’s true for essentially anyone and everyone but perhaps even more so when applying to competitive fields, advanced specialties requiring a preliminary year, or field/location combinations you are not necessarily competitive for. The bright side is that it’s a temporary problem, and in a few extra months you’ll probably have a job and a very expensive piece of paper that says you’re qualified for it. Like other (sometimes more expensive) alternative sources, I have compiled some sage and mostly common-sense advice for how to approach (and succeed in) the match.

Below are some additional thoughts to aid those who are considering pursuing a career in diagnostic radiology.Read More →

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