Rad resident "existential crisis"

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sethgeks

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Hi everyone,

I'm a fresh new rad resident, and since the beginning I have been asking myself au lot of questions about the specialty: I hear a lot of residents and doctors from the other specialties telling that they don't need to read our reports and they can read CT and MRI as well as us... It's quite confusing because it appears to be true (ex general surgeons, oncologists, ortho etc). Have you ever feel that way ? I sometimes feel like a technician.

Thanks
 
They can’t. Well, it’s variable. Some of them are good and some terrible.

Certainly, they don’t look at things outside of their specialty.

For example: Some neurologists are *ok* with brain imaging. But will suck at the bones, They definitely wouldn’t catch something in the pharynx or sinuses.

It’s actually just a case of overconfidence. People don’t realize how complicated imaging is because they don’t do it. They don’t know what they don’t know. If you put them on call for a night they would find out.

If they don’t read the reports, they’re just begging to hurt someone or get sued.
 
They can "read" within their clinical subspecialty, but they will never put their name on a report and be responsible for every pixel on the scan. This includes (as mentioned above) areas outside of that doctor's specialty, atypical presentations of common conditions, and basically anything else a Radiologist is expected to pick up on any scan.
 
I have learned a considerable amount after training from the specialists on how they look at imaging and what they find important from a scan. I have been impressed by how much they know about imaging. Their pattern of review is much different compared to how I was trained to look at imaging. I think that they are very focused on the condition that they know.

There are some neurologists who read neuroimaging/spine and there are cardiac imagers who read cardiac CT and MRI. OB can read pelvis ultrasound and Vascular specialists (surgeons, cardiologists, etc) are able to read vascular ultrasound, musculoskeletal (arthropods). These are even formally read by these specialists. This made me realize that imaging/interventions are not the sole right of any single specialty.

Abdominal imaging encompasses so many organs that one single pure clinical specialist would have a challenge interpreting all of the organs/specialties covered. Aorta/IVC (vascular specialist); Adrenals, Kidney , Ureter , Bladder, prostate (urology/nephrology); Intestinal pathology (general surgery); Spine pathology (Ortho/Neurosurg); Liver, bile ducts, gallbladder, pancreas (hepatobiliary surgery/GI); uterus and ovaries (gynecology). I believe that it will be a challenge for anyone but a general radiologist to interpret body CT well.

There are some facets of imaging radiologists are doing less and less of. Most radiologists don't knowhow to interpret echocardiography, TEE, cardiac caths. ERCP interpretation is also becoming a lost skill. Fewer radiology training programs are educating their trainees on vascular ultrasound (NIVL); abi,segmentals, PVRs etc. Point of Care ultrasound is really taking of and the sports medicine physicians have gotten much better at MSK us, the intensivists are pretty good at identifying pneumothorax, kerley b lines, IVC collapse etc that many radiology trainees are not learning. I have noticed that over time radiology trainees do less and less of their own ultrasound and it is primarily us technologist driven so their ability to scan is falling by the waist side. The clinical specialists on the other hand are using this on a more routine basis even on daily rounds.

So, I think that our skills and the clinical specialists skills go had in hand and we should collaborate with them more to really become good imagers. Ideally participate in the multi-disciplinary conferences including tumor boards and get constant feedback on your interpretations with pathologic proof, operative proof and /or clinical outcomes.
 
As mentioned, many specialists are quite good at a narrow cross-section of medical imaging, and these types tend to be concentrated in academia. However, if you have the means, go spend a day with a radiologist in the community. Chances are that you'll realize quite quickly two things: 1) many providers are generalists and rely heavily on radiologists and 2) that specialist who is so good at reading their studies would have never gotten the consult if the radiologist hadn't told the CRNP in the ED to call neurology.
 
In private practice most physician don't look at the imaging themselves with the few exceptions.

This crap of "I read my own imaging and don't read the reports" belongs to academic centers where the "high ego" of some "Pathologic personalities" don't let them even think that somebody in the planet knows something better than them.

In your post you mentioned oncology. That is not true. Oncology is heavily dependent on radiology even in the biggest academic centers.

As more and more healthcare is provided by primary care provides in this country (IM, hospitalist, PAs, NPs and ED), radiologists role become more and more important.

Most community hospitals are run by ED, Hospitalist, radiologist and a general surgeon.
 
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Medical oncologists are in general not the best at imaging and they rely heavily on the radiologist interpretation. Primary Care, ER, hospitalists, PA/NPs, Urgent care will rely heavily on advanced imaging interpretation by the radiologist. Screening studies such as lung cancer screening and mammography is driven primarily by radiology. By the time they are seeing a specialist there is some idea of what the problem is.

Radiation oncologists and newly graduated organ based oncologic surgeons are good at their focus of imaging. The newer graduates are becoming more and more comfortable with imaging as they grew up in the era of PACs and started looking at films as early as medical school. Graduates that are over 5 years out of training in smaller groups are less inclined to be facile at advanced imaging unless they are ortho and neurosurgery.
 
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I have looks at a tons of CXRs, lots of ct brains, mri brain and to a degree I can see big things in ct ab/pelvis. I don’t think I can read them “as good” as a radiologist, but I can make urgent decisions in my scope of practice (also increases my MDM). I know radiologist look at a ton more images than I do. They also have a ton better screen.

I do get annoyed when they put, pneumonia, effusion, vs. heart failure, but that is life.

I also realize that I have the patient, they don't. They also make mistakes, but only a ***** would say they are only technicians. it essentially is a mini-consult with every image, though only old school radiologist get clinical info before giving a read.
 
Don’t worry, we still need you.
- your friendly neighborhood internist who can spot a big infiltrate/effusion or saddle PE and verify a standard line/tube placement but is still otherwise definitely waiting on your read.
 
Having trained both in the community and at a large academic center, there are definite differences in how the referring clinicians view their abilities to interpret diagnostic imaging. In the community/private practice setting, the radiologist is instrumental in guiding patient dispo and alerting the clinicians to unexpected or critical findings. Specialists are too busy with their own services to pore over images. The important thing is knowing what the referrers at your particular institution care about and providing a clinically useful dictation.

It is unfortunate that some radiologists refuse to commit to anything or feel inclined to recommend unnecessary follow up as a means of CYA. Clinicians place far greater value on an unambiguous report that tries to address the question at hand and are more forgiving of an incorrect interpretation than they are an impression that includes every possible differential and ultimately doesn’t help them.

Big picture pathology is not hard to identify (eg stroke, bleeds, free air, displace fractures) and an experienced clinical specialist should be able to see these things. As any rad knows, these are not the cases that prove your worth as a consultant. We have to own the corners of every exam and be versed in multi system pathophysiology lest we overlook something subtle. I don’t know any clinician who reads the survey images of an abdominal MRI but I do know 2 colon cancers I’ve caught on them.

Also, to the post above, pneumonia is and always will be a clinical diagnosis.


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sethgeks said:
Hi everyone,

I'm a fresh new rad resident, and since the beginning I have been asking myself au lot of questions about the specialty: I hear a lot of residents and doctors from the other specialties telling that they don't need to read our reports and they can read CT and MRI as well as us... It's quite confusing because it appears to be true (ex general surgeons, oncologists, ortho etc). Have you ever feel that way ? I sometimes feel like a technician.

Thanks
Click to expand...

It depends on where you are as well.

I'm training at an enormous tertiary referral/transplant/level one trauma blah blah blah medical center. Our docs are great at catching things that will hurt their patients right away. Vascular Medicine and Vascular Surgery are great with the vessels on the CTA, Neuro is going to pick up the strokes/big aneurysms/demyelinating diseases/etc, General Surgery is going to pick up the appendicitis. Each of the above respective cases are going to miss the renal cancer, often not understand the difference in potential underlying diagnoses with vasogenic vs cytotoxic edema on the head CT without contrast, and miss that the appendicitis is actually secondary to terminal ileitis/Crohn's disease. With all that said, it actually makes me feel better knowing that, if I miss something significant on call (reading at speeds well beyond my comfort zone), the primary team is probably going to be all over it and it's unlikely that harm will come to the patient.

It's easy to feel like a technician as a first year radiology resident because the attendings in the other specialties probably can read the imaging of their specialty better than you can, but it's all a matter of experience. You'll realize soon enough, overnight as a senior resident when the chief of ER or trauma or neuro attending comes in to talk about a case, that they respect your knowledge and that you truly do provide a service for the hospital and patient.
 
NITRAS said:
I have looks at a tons of CXRs, lots of ct brains, mri brain and to a degree I can see big things in ct ab/pelvis. I don’t think I can read them “as good” as a radiologist, but I can make urgent decisions in my scope of practice (also increases my MDM). I know radiologist look at a ton more images than I do. They also have a ton better screen.
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Come on, man. Don't start with that nonsense.

The resolution of my home desktop monitor is sufficient for CT and MRI, so my PACS has absolutely nothing to do with why I'm better at reading those modalities than you are. That's like me saying you can auscultate the heart/lungs better because your stethoscope is better than mine. The Pathologists also just have better microscopes than I do.

I do get annoyed when they put, pneumonia, effusion, vs. heart failure, but that is life.
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If you don't understand why we can't be definitive sometimes, you don't understand the basic limitations of the imaging you're ordering. Maybe "that is life" means you do understand the limitations. I don't know.

I also realize that I have the patient, they don't. They also make mistakes, but only a ***** would say they are only technicians. it essentially is a mini-consult with every image, though only old school radiologist get clinical info before giving a read.
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It's actually simple math. If I'm reading 200+ studies per 12 hour shift, I can't dedicate 3 minutes per CXR (probably up to/around 2.5 hours, a conservative estimate with two of our EMRs) to dig up why you ordered the CXR. If it's a complex or confusing case, yes I'm going to look up history.
 
Radiologists are essential personnel, I can assure you not every study in the community gets reviewed by a regional subspecialty expert or a senior surgical resident with a half hour to kill unlike at your tertiary care center.
 
CaptainSSO said:
If they don’t read the reports, they’re just begging to hurt someone or get sued.
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+1

Skilled referring clinicians can independently pick up #1 and maybe #2 on your impression, but less likely #3 and #4, whether due to time constraints, lack of systematic approach, lack of knowledge of pathology outside their area of expertise, or technical and environmental reasons (low quality images and subpar hanging protocols on the web viewer on a nondiagnostic monitor in a bright and chaotic clinical environment). Radiologists make wrong interpretations sometimes, particularly in the absence of clinical information. If a referring clinician disagrees with a read, that's fine and they should document so, but skipping the radiology report altogether is asking for trouble. An important finding will be missed least frequently by the clinician who both reads the report and looks at the images, next least frequently by the clinician who only reads the report, and most frequently by the clinician who ignores the radiology report and only looks at the images themselves. Follow up on enough cases and you will see it happen. This applies for both missed incidental (unexpected) findings and also misinterpretations of clinically suspected findings. Don't let others' negligence discourage you from doing the right thing for the patient.

There are many examples of important incidental findings that were actually caught by a radiologist but ignored. One prominent case was highlighted by Atul Gawande: Peter Franklin vs. Thomas W. Albert and MGH (FRANKLIN vs. ALBERT, 381 Mass. 611): The Malpractice Mess | The New Yorker
 
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NITRAS said:
I have looks at a tons of CXRs, lots of ct brains, mri brain and to a degree I can see big things in ct ab/pelvis. I don’t think I can read them “as good” as a radiologist, but I can make urgent decisions in my scope of practice (also increases my MDM). I know radiologist look at a ton more images than I do. They also have a ton better screen.

I do get annoyed when they put, pneumonia, effusion, vs. heart failure, but that is life.

I also realize that I have the patient, they don't. They also make mistakes, but only a ***** would say they are only technicians. it essentially is a mini-consult with every image, though only old school radiologist get clinical info before giving a read.
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The "better screen" fallacy is similar to someone who can not run due to being overweight but attributes it to "not having good running shoes". It is a total BS. Except for mammogram and some nuances on CXR, everything else can easily be interpreted from a usual computer screen.

This happens when you "think" you "can make urgent decisions yourself":

Hospital's mistake leaves single mom with 6 months to live

Summary: ER doctor "Thought" he could "make urgent decisions" because "he has looked at tons of CXRs" similar to what you described above. He didn't look at the radiology report that described some suspicious findings. End result: Due to ER doctors "neglect", unfortunately a patient died of stage 4 CA and his career and the radiologist's career were endangered big time.
 
I can make urgent decisions myself (use the tube, retract the tube, stick the ptx). I can’t reliably detect non-huge nodules and appreciate that radiologists can. Sounds like a tragedy of missed follow up opportunities over years. Lung module follow up is not an urgent decision.
 
I am currently at a large academic center but moonlight at small community hospitals in the region. I read about 400 studies over the weekend. I also do procedures (drains, lines, LPs, etc). I’ve done face to face consults with surgeons who get called by the ED. They want to definitively know if they should cut. I also have conveyed unexpected cancers in someone with suspected diverticulitis. Clinicians generally appreciate what we do and are amazed by our breadth of knowledge across many organ systems. The clinician that doesn’t respect this subspecialty doesn’t realize their own subspecialty. It’s like the surgical PA who gets to scrub and do quite a bit in surgery who says “they’re essentially a surgeon.” But it just takes nicking an artery and the patient coding for them to take a step back.

I have a great case for med students of a shoulder pain patient with a shoulder radiograph who had a lung mass. The info was conveyed, but the patient never followed up and presented to the ED with SOB 3 months later. Stage 4 disease on the subsequent imaging.

I’ve also had the experience of looking at a brain ct perfusion and the Neuro resident knew about the stroke and vessel cutoff. Somehow they missed the 5 cm mass in the chest.

And I just have to identify the normal gallbladder as not a suspected liver mass to the clinician who calls about what that “mass” is to know that I won’t be out of a job.
 
Depends on the situation. From what I've seen, surgeons are close to the level of a radiologist when examining for a known clinical entity (within their specialty) AND also have the benefit of being able to physically see and examine the patient. As such, when they know exactly what they're looking for because the H&P are clear, they generally do very well. E.g. A trauma surgeon/orthopod has no trouble looking at a knee XR for a patient post-MVC to r/o fractures.

For situations where the H&P isn't clear, or if they're imaging for something outside their specialty, or if they just can't look at the imaging themselves, the radiologist's report becomes critical. In community centres, often surgeons don't bother with imaging because they're too busy or can't easily access it. In academic centres, often patients are complicated enough that a radiologist is needed to scan for incidental but potentially significant findings.

At the end of the day, you won't make a difference in every patient, but reads from radiologists are critical to the hospital and general patient care.
 
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