Annoying radiology mis-calls

[neglect]

Over the past few months I've had growing irritation at radiologists and neuroradiologists who misread images. Not only the unhelpful reads that list every category of disease, like 'inflammation or infection or trauma or vascular,' but just bad calls. I suppose what annoys me about this most of all is that for all these errors, radiologists will swear on a stack of bibles that no neurologist could ever hope to read a study (nor anyone in India or Ireland).

Here is one case that provoked some irritation. There are others in my own experience. How about you?

Case: young and confused with long track signs all over, no fever. Head CT showed frontal hypodensities. MRI read as c/w old trauma - totally wrong - it looked nothing like trauma (medial and lateral hyperintensities in frontal lobe). End result: viral encephalitis, type unknown.

Am I just crazy to be this annoyed? The academic year turned over, and I'm a freshly minted fellow now, but this stuff really got under my skin. I love it when the radiologist adds to a case, and brings another pair of eyes, but sadly this seems to be a rare event. Any other cases?

---

Members don't see this ad.

 

[radswannabe]

Don't be a playa hata just because radiologists are making mad bank and you're not.

Over the past few months I've had growing irritation at radiologists and neuroradiologists who misread images. Not only the unhelpful reads that list every category of disease, like 'inflammation or infection or trauma or vascular,' but just bad calls. I suppose what annoys me about this most of all is that for all these errors, radiologists will swear on a stack of bibles that no neurologist could ever hope to read a study (nor anyone in India or Ireland).

Here is one case that provoked some irritation. There are others in my own experience. How about you?

Case: young and confused with long track signs all over, no fever. Head CT showed frontal hypodensities. MRI read as c/w old trauma - totally wrong - it looked nothing like trauma (medial and lateral hyperintensities in frontal lobe). End result: viral encephalitis, type unknown.

Am I just crazy to be this annoyed? The academic year turned over, and I'm a freshly minted fellow now, but this stuff really got under my skin. I love it when the radiologist adds to a case, and brings another pair of eyes, but sadly this seems to be a rare event. Any other cases?

 

[neurosign]

What does neglect's post have to do with how much money rads make? He is merely pointing out the incompetencies of radiologists, which is further compounded by the fact that they do not collect direct H&Ps to come up with a logical differential, a skill required to be a true physician.

Rads have a one track mind and fail to see the reality of an argument not dealing with money. Open up your mind man. We could care less about how much they make as long as useful contributions are made to patient care. Yes, that's right, patient care...a long-forgotten goal in medicine.

 

[kasimagore1]

just to bring up a counterpoint: it's not the job of a radiologist to obtain H&P, it's the requesting physician's responsibility to convey this information to the radiologists. most of time the reason(s) for a specific study on the requisition is oversimplified (especially those requisitions written by ER): altered mental status, acute onset of gait instability, etc etc.....of course the radiologists would provide a laundry lists of Ddx when they look at the films....unless something is very obvious like ICH or a big tumor crossing midline. It's your responsibility, as the neurologist, to correlate the radiographic findings with the H&P and whatever other lab findings at your disposal. How specific do you think a viral meningitis or encephalitis would show up on CT or MRI? The imaging studies give you just another piece of information, it doesn't make diagnosis for you...it is your job to make the diagnosis.

 

[neurosign]

I partly agree with that but my statement was in defense of the monetary issue and the tendency of future rads to use it as an argument for many topics discussed on this forum.

 

[radswannabe]

I partly agree with that but my statement was in defense of the monetary issue and the tendency of future rads to use it as an argument for many topics discussed on this forum.

Playa hata.

 

[neurosign]

Yeah you keep hating, I'll keep playing.

 

[kasimagore1]

I partly agree with that but my statement was in defense of the monetary issue and the tendency of future rads to use it as an argument for many topics discussed on this forum.

My comments were mostly for the OP.

 

[radswannabe]

Yeah you keep hating, I'll keep playing.

You must have your PhD...Playa Hata Degree

 

[neglect]

just to bring up a counterpoint: it's not the job of a radiologist to obtain H&P, it's the requesting physician's responsibility to convey this information to the radiologists. most of time the reason(s) for a specific study on the requisition is oversimplified (especially those requisitions written by ER): altered mental status, acute onset of gait instability, etc etc.....of course the radiologists would provide a laundry lists of Ddx when they look at the films....unless something is very obvious like ICH or a big tumor crossing midline. It's your responsibility, as the neurologist, to correlate the radiographic findings with the H&P and whatever other lab findings at your disposal. How specific do you think a viral meningitis or encephalitis would show up on CT or MRI? The imaging studies give you just another piece of information, it doesn't make diagnosis for you...it is your job to make the diagnosis.

I don't think this is a counterpoint. It is a point. Obviously radiologists read the scan. I'm just bothered because they do so in such a vacuum of clincial isolation. Obviously it is the job of the neurologist to fit the study into the impression and plan. My point is that I'm a bit bothered by the poor quality of the reads. I gave an example where radiology not only failed to add value, but where it detracted from diagnosis.

I think that imaging has revolutionized our field. This is clear if you spend a half a day with an older neurologist. They will talk about this and that, stress the importance of some key part of the history and physical - but we no longer pay attention to it because that idea has been falsified. For an interesting talk, go ask some old neurologist how they identified bleed/bland strokes. He'll talk about subacute presentations, highly elevated BP, and we now know that none of that matters at all. The money's on the CT. Like I said, technology has done great things for neurology. I'm just not sure radiologists have done great things for neurology. In fact, several other cases have made me think that they do not.

Radswannabe is clearly an idiot. Personal financial issues are something that clearly concern him. I'd be an idiot as well if I said they don't concern me, but they clearly do not concern this post. I'm happy that radiologists do well. A few of my friends are radiologists. Cool for them.

A few of my friends are in gen IM, FP, and peds. As a neurologist I'd be pretty damn stupid to assume that because I will make more than them, this means anything other than that. Everyone has their role to play - the respect you obtain has less to do with which role you've gotten than with how you play the one assigned. And if you think that only your salary is going to make you rich, then you are incorrect.

 

[neurosign]

Speak your mind neglect! Amen.

 

[f_w]

It is funny how dead the neurology forum is until someone brings up imaging and/or radiology.

If there are issues with the quality of the neuroradiology reports at your hospital, bring it up with the medical board. If you can indeed show that the quality of the reports is sub-par, the local group can either be 'motivated' to hire a neuroradiologist, or the neuro studies can be taken out of the contract and sent to a dedicated neurorad practice.

I'm just bothered because they do so in such a vacuum of clincial isolation.

The clinical isolation is only as big as the void you leave on your requisition form. If you are too lazy to fill out this request for a consultative service and leave it up to your MA to scribble 'r/o headache' on every MRI req, don't be too suprised if you get very nonspecific reports back.

I suppose what annoys me about this most of all is that for all these errors, radiologists will swear on a stack of bibles that no neurologist could ever hope to read a study

Talk about an oversimplification. 'Radiologists' don't swear on a stack of bibles that no neurologist can read an MRI. What our professional association is fighting, is the tendency of neurologists and other specialists to line their pockets with self-referred imaging done in poor quality.

I have trained in both areas, neurology and radiology. I have the greatest respect for any neurologist who takes his time to read up on neuroradiology and who is able to make sense of the imaging findings him/herself. I have NO respect for some neurologists who have no f#*$^% idea what they are talking about when it comes to imaging, but are completely convinced that everything is an evil conspiracy by the radiology lobby.

 

[neglect]

Patient with a late life onset headache. Already thinking secondary. The patient is worst historian: a "you figure it out" type and a positive ROS. Everything makes the HA worse, nothing makes it better. Exam is normal.

MRI shows enhancement of meninges. Radiology read suggests infection. Go see the scan - there are also low lying tonsils, not mentioned in the report. I'm told it is a normal varient.

The CSF leak was found in the L-spine. Blood patch with resolution.

 

[eddieberetta]

How was the CSF leak found?

 

[neglect]

How was the CSF leak found?

It was obvious on L-spine sag. It went to attending level to get the total spine btw.

Confused old demented person who normally speaks fairly sensibly, now not speaking at all, otherwise non-focal, no obvious cause during ER lab workup. Normal head CT by report and by radiology (not neurorad read, but this was final read) Nope. I know it's hard to see the temporal horn, where the huge wedge-shaped hypodensity was present, but it was there. And follow up confirmed it. Stroke - not that there was much to be done about it. This was subtle though - and you really did need to put 2 and 2 together and take a careful look at the language centers. No points off for that one - but I have dozens more.

 

[eddieberetta]

I am not sure about the purpose of your rant. Humans are fallible, and no-one will go through life without making errors. I cannot speak for your experience but in my short time taking call in radiology, I have had many instances where I have made significant findings that were missed by referring services including neurosurgery and neurology, including fellows/staff.

My first night on call gross leptomeningeal enhancement in a "stroke" patient who went on to have LP proven bacterial meningitis was missed by a staff neurologist. I have found incidental lines and tubes in wrong places, incidental PEs and DVTs on cross sectional studies, and countless other findings that have had a major impact on patient care. This in addition to the bread and butter slam dunk cases that we still get called about all the time (i.e. they are slam dunks only if you have had the training/experience to recognise them as such).

Are you saying that you have never missed a significant finding that was detected by a radiologist? If so, you have missed your true calling in life!

Radiologists are not infallible, any more so than any other physician. As a non-radiologist, it is not expected for you to know imaging, and it would seem very easy to remember the times when you picked up something missed by a radiologist (many times, aided by more specific clinical data). But interestingly I have noticed that unlike Neglect, most referring MDs remember your triumphs rather than your mistakes.

 

[radswannabe]

"Radswannabe is clearly an idiot. Personal financial issues are something that clearly concern him. I'd be an idiot as well if I said they don't concern me, but they clearly do not concern this post. I'm happy that radiologists do well. A few of my friends are radiologists. Cool for them."

I'm just clearly a PIMP baby!

 

[neurosign]

wow...

 

[neglect]

EB: I'm sure you're very good at what you do. You certainly sound like you take your work very seriously, and that makes all doctors and patients you're involved with appreciate you.

I'm mostly concerned that neurorads is clinically isolated from outcomes and treatments. So much of the report consists of useless information. "Hypodensities in the periventricular space likely represent small vessel disease." Sure. "Ventricles larger than expected for age. Clinical correlation..." Right.

I'm not saying that I'm infallible. Nor am I saying that I'm a radiologist. I'm saying that when you have all the clinical data, which can be cloudy, and you know what you're looking for and know how to look for it, then most neurologists trained in the 90's and beyond can read scans pretty well. I'm saying that radiologists make errors based on their lack of insight into eventual treatment plans.

74 year old with an INO and a history of right hemiplegia with full resolution. MRI is read as consistent with MS based on periventricular white matter lesions and atrophy. I have no idea where they got that from other than history. Actual diagnosis: stroke.

 

[f_w]

Again, what have you done to address the perceived quality problem with neuroradiology reports at your institution ?

 

[neglect]

Again, what have you done to address the perceived quality problem with neuroradiology reports at your institution ?

Sorry I didn't answer this.

Case by case, first of all.
We also have an onc conference, which I sometimes go to.
We also have a stroke conference, which is supposed to be vascular surg, IR, neurosurg, neurology, and rads - but turns out to be IR, neurology, and neurosurg.

On these second two, I have seen fellows, but never radiology residents.

 

[f_w]

I assume you are a resident. Have you motivated your staff to bring this issue at the next medical board meeting ?

Have you taken the reports and gone back to the radiologist, or his department head ?

Bitching about it in an anonymous internet forum is not going to benefit your patients. If there is indeed a quality problem with the neurorad coverage at your hospital, do something about it.

 

[neglect]

I assume you are a resident. Have you motivated your staff to bring this issue at the next medical board meeting ?

Have you taken the reports and gone back to the radiologist, or his department head ?

Bitching about it in an anonymous internet forum is not going to benefit your patients. If there is indeed a quality problem with the neurorad coverage at your hospital, do something about it.

From you post, I gather you're either a medical student or an intern at a private hospital. Residents do not stamp their feet and get what they want.

16 year old with alteration in MS, hyperintense bilateral basal ganglia on T2? Hint: the dude has Bechet's. Well, actually he doesn't, but he does have IBD.

 

[f_w]

> From you post, I gather you're either a medical student or
> an intern at a private hospital. Residents do not stamp
> their feet and get what they want.

How cute. I am BC radiologist and current fellow ;-))

If some service f()@# up one of my patients (like yesterday for example), I will do whatever I can to make sure that this doesn't happen again. And if this involves a trip to the chief of staff's office, some residency director or conferences with risk management and the nursing manager, so be it.

Running your mouth here is easy, addressing a problem such as this would actually require courage. If there are clear misses, collect them, go to head of your department and give him the ammunition to light a fire under the radiology chairmans behind (If this is just stuff you either made up or embellished for your own glorification, you might not want to do that).

At least were I did my residency, clinicians (including neurologists) would get back to us if they disagreed with a report. If it was indeed a miss or an incorrect interpretation, it would be discussed in the weekly QA conference and the report was amended. If it was just a case of the imaging diagnosis not fitting the clinicians expectations or prejudices, the issue was discussed and the report remained unchanged.

 

[neglect]

>
If some service f()@# up one of my patients (like yesterday for example), I will do whatever I can to make sure that this doesn't happen again. And if this involves a trip to the chief of staff's office, some residency director or conferences with risk management and the nursing manager, so be it.

Running your mouth here is easy, addressing a problem such as this would actually require courage. If there are clear misses, collect them, go to head of your department and give him the ammunition to light a fire under the radiology chairmans behind (If this is just stuff you either made up or embellished for your own glorification, you might not want to do that).

At least were I did my residency, clinicians (including neurologists) would get back to us if they disagreed with a report. If it was indeed a miss or an incorrect interpretation, it would be discussed in the weekly QA conference and the report was amended. If it was just a case of the imaging diagnosis not fitting the clinicians expectations or prejudices, the issue was discussed and the report remained unchanged.

PLEASE! Like I exist to educate. No thanks. It takes courage to stab people in the back and rat them out to my chairman (who probably cares as much as I do) to try to force him to change things? You have a funny way of defining courage. Again, no thanks. I do, however, enjoy stirring things up on these boards and have been board.

As I said, I take these things on case by case with the people involved. But the overall problem I've noticed is that neuroradiology exists in it's own little world. While it concerns itself with periventricular white matter disease and sinusitis, it does not concern itself with being of great help. And I was wondering if that is the case in other locations. One of the greates problems I see with radiology is that they exist to read scans, but have no compulsion to tie these readings in with overall plan and treatment. Why? Because that's what neurorads does not do - other than the IR people (who are amazing should everything go really really well, and if not, then not).

None of these mistakes really impact care because the neurology teams pretty much know what they're looking for. So no-one's exactly messing up care. It's just that the service isn't as helpful as it could be.

In the cases where there is confusion (is this a glioma, ADEM, or infection - and we have a quick question about NAA), then neuroradiology is great.

Ascending sensory loss to T2 in a young woman. She is not functional and has an anatomic exam. C and T spine clean. Hum... Why would we want a brain MRI? Hint: it's on the history.

 

[radswannabe]

PLEASE! Like I exist to educate. No thanks. It takes courage to stab people in the back and rat them out to my chairman (who probably cares as much as I do) to try to force him to change things? You have a funny way of defining courage. Again, no thanks. I do, however, enjoy stirring things up on these boards and have been board.

As I said, I take these things on case by case with the people involved. But the overall problem I've noticed is that neuroradiology exists in it's own little world. While it concerns itself with periventricular white matter disease and sinusitis, it does not concern itself with being of great help. And I was wondering if that is the case in other locations. One of the greates problems I see with radiology is that they exist to read scans, but have no compulsion to tie these readings in with overall plan and treatment. Why? Because that's what neurorads does not do - other than the IR people (who are amazing should everything go really really well, and if not, then not).

None of these mistakes really impact care because the neurology teams pretty much know what they're looking for. So no-one's exactly messing up care. It's just that the service isn't as helpful as it could be.

In the cases where there is confusion (is this a glioma, ADEM, or infection - and we have a quick question about NAA), then neuroradiology is great.

Ascending sensory loss to T2 in a young woman. She is not functional and has an anatomic exam. C and T spine clean. Hum... Why would we want a brain MRI? Hint: it's on the history.

Neglect, it's never too late to switch into radiology. Maybe you can talk to the PD.

 

[f_w]

> No thanks. It takes courage to stab people in the back and rat
> them out to my chairman (who probably cares as much as I do)
> to try to force him to change things? You have a funny way of
> defining courage. Again, no thanks.

Either, there is a problem, or there is none. If there is none, why are you so bothered, if there is one, you are failing in your job if you don't address it.

> While it concerns itself with periventricular white matter disease
> and sinusitis, it does not concern itself with being of great help.

Can't win. If we mention the sinuses, we get belittled for focussing on such a peripheral problem, if we don't mention it we have some smart-aleck neuro resident come and call us on the 'miss'. (you know, this could be one reason for this guys headache, you know)

> but have no compulsion to tie these readings in with overall plan
> and treatment.

If we get useful clinical information on the requisition, we try to tie the imaging findings in with this history. But unfortunately, we rarely get anything beyond 'vertigo' 'r/o stroke' (or other nonbillable r/o bull#^$*).

> because the neurology teams pretty much know what they're
> looking for.

And that tends to be the problem. You know what you are looking for. If it shows something you weren't looking for, you won't see it.

Good luck.

 

[neglect]

> Can't win. If we mention the sinuses, we get belittled for focussing on such a peripheral problem, if we don't mention it we have some smart-aleck neuro resident come and call us on the 'miss'. (you know, this could be one reason for this guys headache, you know)

Exactly!!! You made my point, thank you. Radiologists, generally, live in a vacuum of clinical experience, so they say things like this: that sinusitis may be the reason for headache, and do not recognoze it as an incidental finding. Do you think that the PCP may have missed the fever, purulent drainage, abnormal smell? I don't exactly fault you. Many ENT people continue to treat migraines with various procedures and amox and sudafed.

If we get useful clinical information on the requisition, we try to tie the imaging findings in with this history. But unfortunately, we rarely get anything beyond 'vertigo' 'r/o stroke' (or other nonbillable r/o bull#^$*).

Hum... You ought to think about contacting your program director and making a big fuss about this. As you know, other options include: the "chief of staff's office, some residency director or conferences with risk management and the nursing manager."

Oh, and I misspoke - the neuro team should know WHERE to look. Thus we tend to see the relevant things that you miss, and disregard the things you pay so much attention to.

The previous cases, since you didn't want to guess, were central venous thrombosis and obtaining a brain MRI after the first demyelinating episode.

Another case: lthough strokes can present with seizures, round hyperdense areas within the "stroke" might draw your attention to an alternative diagnosis.

 

[neglect]

Neglect, it's never too late to switch into radiology. Maybe you can talk to the PD.

No thanks, but thanks anyway. There's something for everyone, but rads is not for me. I couldn't derive enough satisfaction out of it (other than in a financial way, which would not keep me going for too many years). I enjoy radiology in relation to reality, not in relation to going from the unread pile to the read pile, so neurology is a good place for me. Also, interpreting neurophysiology studies is really cool, since you are usually the treating doctor, it dovetails into treatment nicely.

But if you can stand the darkness, then good for you!

 

[Whisker Barrel Cortex]

Ok, so you started it.

Idiotic neurology moments:

Neurology resident is reviewing an MRI we did on a patient with dizziness when he tilts his head back. His attending neurologist had looked at the scan and thought there were bilateral vertebral dissections. The resident looked at it and thought there was a basilar tip aneurysm. In actuality, the verts had normal flow artifact centrally and the basilar tip was normal.

Neurology resident (3rd year) and stroke fellow want me to look at an outside CT prior to stroke MRI b/c they are worried about possible metal in the orbit. I can't see anything there so I ask them to point it out and they point out a fat attenuation area in the eyelid.

Neuro-stroke attending (and rad resident) looks at head CT on stroke patient. No bleed is called. When staff neuroradiologist looks at it, calls small bleed. Pt was started on anticoagulation based on neurologist and resident read. Pt develops severe bleed and eventually dies.

Petty neurology resident/wanna-be-neuroradiologist comes on an internet message board and bitches about neuroradiology.

Your assumptions that radiologists don't care about being helpful is completely untrue. The vast majority go out of their way to be beneficial to the patient and the clinician. Of course things are missed or misinterpreted. Do we feel bad when they are? Of course. The idea is to learn from these mistakes to lessen the probability that they will occur again.

 

[f_w]

> Exactly!!! You made my point, thank you.

I am not sure how I made your point. It is a finding, it might have clinical significance, I'll mention it as such (often enough, our heme-onc colleagues will specifically ask to have a comment on the sinuses included in the report, just to be sure we looked at them on every study and they don't have to call back if we didn't mention them.) I don't diagnose sinusitis unless you ask for it.

> Do you think that the PCP may have missed the fever, purulent
> drainage, abnormal smell?

I have given up on the concept of the clinician who actually looks at his patients before he orders a study. Can't assume anything. Actually, our neuro residents were the worst offenders in this arena. They would usually show up 8 hours after the patients had been treated for a stroke and criticize us for doing the GE images in axial instead of coronal plane. If you asked them something clinical such as specifics of the deficit, you would get the 'blank stare'. They were so utterly useless that stroke management was essentially handled between neurosurg, neuro-IR and internal medicine.

> Hum... You ought to think about contacting your program director
> and making a big fuss about this.

Actually, I don't have to, it is not a quality of care issue, it is a mere annoyance. My report will be pretty much the same, whether I have clinical information or not (if it is a protocol issue, I will bounce the requisition back for clarification).

If you are kind enough to give me some clinical information, I can give you a comment in the impression whether the findings support this provisional diagnosis or not, but the finding will stay the same. It is actually a good idea not to look at the clinical history given to avoid the focussed search you are so proud of. Only after I have made the findings to be included in the report, I will check on the clinical history to see whether there is something to be commented on.

You are complaining that your radiologists 'miss' stuff all the time. This IS a quality of care issue and should be addressed (unless of course your stories are freely made up).

 

[neglect]

Yeah, those neurologists were really stupid.

The dizzy patient's MRI fits with neither dissection nor aneurysm. Stupid. Even a junior resident should know that.

And neurology resident looking for metal in an eye, and using a CT as their tool (and not the scout), is an idiot - I agree.

But your last case is interesting to me. Because here is where you get into treatment, and you loose it. So there's a small bleed within a stroke? Who cares? We know that all strokes develop small areas of bleeding, picked up on CT or not. If there are compelling reasons to use anticoagulation (huge DVT is just one example), then you've got to do it. (in case you'd like to know, don't bolus the heparin in setting of stroke - no data, just old heparinist's tales).

The bad outcome in this case may be just bad luck - but the interesting to me is that you don't even see this - because you do not manage patients, so you have no clue as to how your interpretation fits into the overall treatment plan.

This is actually a perfect example (and in many ways better than my own): the small hemorrhage that existed in one picture set is something that rads pays an ungodly amount of attention to, but misses the overall picture. And here is a way for you to be more helpful when reading a scan: "There is a small amount of petechial hemorrhage within the stroke (previously seen, with progression), which is to be anticipated given the size..." Most neurologists will know what you're talking about - normal stroke.

Sadly, I think this is a systemic problem among neurorads, and you have just supported my thesis. Clinical isolation leaves you less helpful and less aware.

I'm sure you do care about being helpful. Your post amounts to that. So read the films - that seems to be pretty important given the lack of skill among the clinicians you deal with - but also think about how your reading fits in with the overall plan. Your reports will also be shorter, so think of it as a bonus.

 

[neglect]

You are complaining that your radiologists 'miss' stuff all the time. This IS a quality of care issue and should be addressed (unless of course your stories are freely made up).

I'm not even capable of making some of it up. And I'm not complaining about radiology missing things: we all do it - it's just annoying when it matters. I'm complaining about neurorad's clinical isolation from the overall picture and treatment plan. This accounts for many misses and useless reports. For an example, see report of bleed within a stroke above.

Another one from my mental file. History says patient with weakness below the neck. It's a consult, and although we rec a C-spine MRI, team obtains head. Read as normal. Review: sag brain shows high C-spine compression.

Like I said, I can't make it up. I can't be bothered to actually. That was a miss, but it was a miss that resulted from not attending to the history and putting the possibilities into clinical context.

 

[eddieberetta]

The bad outcome in this case may be just bad luck - but the interesting to me is that you don't even see this - because you do not manage patients, so you have no clue as to how your interpretation fits into the overall treatment plan.

This is actually a perfect example (and in many ways better than my own): the small hemorrhage that existed in one picture set is something that rads pays an ungodly amount of attention to, but misses the overall picture. And here is a way for you to be more helpful when reading a scan: "There is a small amount of petechial hemorrhage within the stroke ...

It is not clear that they were talking about petechial hemorrhage; the imaging appearance of the hemorrhage, underlying infarct and time course would clarify that, information not given so far. In any event, I feel that this information should be conveyed to a physician whi is about to start anticoagulation, and I disagree with your assertion that this proves radiologists miss the big picture. Are you saying we don't know about petechial hemorrhage (a finding documented extensively in OUR literature)?!

On the other hand, I think you need to go back to imaging boot camp:

And neurology resident looking for metal in an eye, and using a CT as their tool (and not the scout), is an idiot - I agree.

CT is a definitive modality for excluding intraorbital metal, and I would like to stress for the benefit of others on this board that a CT scout is NON DIAGNOSTIC! (However, a neurologist who cannot tell the diffference between fat and metal on CT better program the radiology number into their speed dial!)

 

[neglect]

It is not clear that they were talking about petechial hemorrhage; the imaging appearance of the hemorrhage, underlying infarct and time course would clarify that, information not given so far. In any event, I feel that this information should be conveyed to a physician whi is about to start anticoagulation, and I disagree with your assertion that this proves radiologists miss the big picture. Are you saying we don't know about petechial hemorrhage (a finding documented extensively in OUR literature)?!

No, you misread me. I'm saying that making a big deal about petechial bleeding is silly. The poster gave a case with the information as given, and used this as an example of a BIG MISS from neurology, which it very well might have been. However, petechial bleeding within a stroke is known to occur, it is thought to be venous, and it would probably not change management with regard to anticoagulation - should it be required.

CT/Plain film: my point was only that if the metal is seen on the CT, then another great place to look is on the scout. You've got it, might as well use it. I did not mean to imply that the CT scout should be used in exclusion. However, if you don't see it on the scout but do see it on CT, then you should scratch your head. These neurologists sound like absolute idiots - it's actually difficult to imagine the anyone could make the mistake of fat looks like metal - but there you go.

CT is a modality to look for significant metal in the eye, I would not call it the definitive modality by any stretch. Please provide your data.

Because this is an important issue, I dug through a search:

"All patients who have a history of orbit trauma by a potential ferromagnetic foreign body for which they sought medical attention are to have their orbits cleared by either plain x-ray orbit films (two views) or by a radiologist's review and assessment of contiguous cut prior CT or MR images (obtained since the suspected traumatic event) if available." American College of Radiology White Paper on MR Safety

Currently there is a debate raging as to the cost effectiveness of CT vs. plain film. My institution obtains plain films only. In any event, it is up to everyone to maintain MRI safety, but it's in your domain, so feel free to obtain CT scans.

Anyway, it would be interesting to get more history of the stroke bleeder.

Few weeks ago I saw a young woman with bells in the distant past, no recovery, left V1-3 sensory loss, but sym aff corneals. Hearing down on left. MRI was normal! I was a amazed. Thought for sure I'd uncovered a CPA tumor. Cool for her though.

 

[f_w]

Few weeks ago I saw a young woman with bells in the distant past, no recovery, left V1-3 sensory loss, but sym aff corneals. Hearing down on left. MRI was normal! I was a amazed. Thought for sure I'd uncovered a CPA tumor.

You remind me of one of our neurology faculty during residency. He saw mostly neuro-ophthalmology and neuro-otology cases and I think he was good in taking care of them. However, there was a clear inverse correlation between his degree of clinical suspicion for a CP angle mass and the actual presence of such a mass. ('there got to be a leeesion'......)

 

[neglect]

Few weeks ago I saw a young woman with bells in the distant past, no recovery, left V1-3 sensory loss, but sym aff corneals. Hearing down on left. MRI was normal! I was a amazed. Thought for sure I'd uncovered a CPA tumor.

You remind me of one of our neurology faculty during residency. He saw mostly neuro-ophthalmology and neuro-otology cases and I think he was good in taking care of them. However, there was a clear inverse correlation between his degree of clinical suspicion for a CP angle mass and the actual presence of such a mass. ('there got to be a leeesion'......)

That case was actually directed at people who see people and have to make decisions regarding their workup and care.

 

[eddieberetta]

CT is a modality to look for significant metal in the eye, I would not call it the definitive modality by any stretch. Please provide your data.

Currently there is a debate raging as to the cost effectiveness of CT vs. plain film. My institution obtains plain films only. In any event, it is up to everyone to maintain MRI safety, but it's in your domain, so feel free to obtain CT scans.

I am only aware of two modalities used to evaluate for intraorbital metal: radiography and CT. I do not have statistics, but it is generally accepted that CT is more sensitive and specific than radiography for significant metal (if the reverse were true, there would be no "debate raging" re cost effectiveness), hence I consider it the definitive test at present. It can also better define where the metal is and whether it is likely to be mobile in the orbit. Most places do radiography as a screen for at-risk individuals, but if a CT has already been done, it is used instead. Also if there is any doubt on the plain films, CT is the next step.

 

[RADRULES]

Neglect = You need to get a life or get laid, most likely both.

Unfortunately, Neurology doesn't get much respect in the medical community, probably this is not deserved. I am sorry that your clear envy of radiology and neuroradiology has led you down this path of hate. I think you need to re-evaluate your life and look deep to find what makes you happy and do it. You clearly have major issues.

 

[bustbones26]

Okay, at every hospital across the country, there is at least one radiologist on staff that is so terrible that he/she has no business being in practice, and will make frequent mis-calls. But why let a few bad apples spoil the whole barrel? In my experience, all staff knows who the bad apples are and will ask for another opinion from a radiologist with a better track record, who by the way is always more than happy to help out.

In general, one thing I hate about medicine is the wisecracks that specialties all make toward each other. We are all needed and are an integral part of the patient care, don't talk smack on each other.

 

[neglect]

Neglect = You need to get a life or get laid, most likely both.

Unfortunately, Neurology doesn't get much respect in the medical community, probably this is not deserved. I am sorry that your clear envy of radiology and neuroradiology has led you down this path of hate. I think you need to re-evaluate your life and look deep to find what makes you happy and do it. You clearly have major issues.

Right. Well, actually, you are incorrect in every point. And yet for all my faults you posit out of thin air, I feel no need to wage ad hominum attacks. Nor do I feel the need to troll around the X-ray forums. I think your post says more about you than me, and, unlike you, I will not speculate. I'm sure you're happy.

Actually, this is funny, because I was going to start another thread on exactly how excellent neurology is - now that I'm out of residency and a fellow.

 

[neglect]

On another note:

During an interview for a job, I was interested that the neurologists in this practice had a view box in their office. Cool. And there's an interesting reason this is needed.

Apparently, when the radiologist misses something, and events conspire to a bad outcome, neurologists in the past have tried the "I don't get paid to look at films, so I do not" defense - to absolutly no avail. Thus getting good at reading images is essential for training. Neurologists have to read films.

Meanwhile, Society for Neuroimaging: neurologists can get accredited to read films.

 

[banner]

Neglect,

There's good radiologists and bad. There's good neurologists and bad.

The only difference is that bad neurologists can hide behind a bedside manner, as they overdose their patients with heparin or toss clinically useless medications at them such as Aricept. The patient will die or not improve and never know better. Because the Doc smiled at him, the patient thinks he's got a good doctor.

Radiologist mistakes are always scrutinized by a person in the know - another physician.

Truly, only 30% of physicians in any given medical specialty can be considered "good". Probably only 10% excellent. The remainder splits between "average" and "dangerous".

I think, maybe, you're looking at the entire "problem" from only one angle - that of a neurologist. (And since you seem to actually care so much, I'd bet that you're of the 30% that can be considered good). In fact, the entire medical field is plagued by inferior, money-hungry physicians, be it neurologists, radiologists, or plastic surgeons. They all kill people whether they write an H/P or not.

 

[banner]

Additionally, Neglect, if most "clinicians" were actually concerned about the best for their patients, they would take the time to write an appropriate clinical indication for the imaging they order. Good physicians will always do this.

To do otherwise is simply not in the best interest of the patient.

The clinical equivalent, I guess, would be to provide an sloppy, inaccurate "sign-out" on a patient to a covering physician. Or, to write illegible, illogical orders for the nursing staff. Or to amputate the wrong leg in surgery because one was to arrogant or hasty (to start the weekend) to actually check the chart for the agonizing 30 seconds. Or to not check on any studies that you ordered only to find that EKG that's been in the chart for three days shows diffuse ST elevations when the radiology resident discovers it.

I've seen all these in either my intern year or as a rads resident. By your logic, I should be calling for an end to internal medicine and surgery with those stories (and plenty more).

The only person hurt by these shortcuts is the patient. Plenty of sloppy physicians out there both in and out of the reading room.

 

[neglect]

Neglect,

There's good radiologists and bad. There's good neurologists and bad.

The only difference is that bad neurologists can hide behind a bedside manner, as they overdose their patients with heparin or toss clinically useless medications at them such as Aricept. The patient will die or not improve and never know better. Because the Doc smiled at him, the patient thinks he's got a good doctor.

Radiologist mistakes are always scrutinized by a person in the know - another physician.

Truly, only 30% of physicians in any given medical specialty can be considered "good". Probably only 10% excellent. The remainder splits between "average" and "dangerous".

I think, maybe, you're looking at the entire "problem" from only one angle - that of a neurologist. (And since you seem to actually care so much, I'd bet that you're of the 30% that can be considered good). In fact, the entire medical field is plagued by inferior, money-hungry physicians, be it neurologists, radiologists, or plastic surgeons. They all kill people whether they write an H/P or not.

I totally agree with much of this. I'm not sure about your 10-30--60 splits, but that's OK.

I was making attempts at categorizing radiology mistakes. Not limited to: The miss - happens to everyone. Early stroke on CT for example. And then there is the miss that is due to a failure to put together clinical information. There is the overcall (there is probably an example above). And then there is the failed attempt to be helpful.

I think some of these mistakes and failures are due to clinical isolation from overall impressions and plans. And I liked mixing it up and being a pain in the ass.

 

[banner]

I think some of these mistakes and failures are due to clinical isolation from overall impressions and plans. And I liked mixing it up and being a pain in the ass.[/QUOTE]


I think there's some merrit to your arguement.

But, I think the true solution to the problem that results in the best patient care is to improve communication between clinicians and radiologists and not to eliminate radiology. Providing good clinical indications would help to limit the clinical isolation and let the radiologist in on overall impressions and plans.

A radiologist can not read the mind of the clinician for nebulous clinical indications (for example, "pain" or "r/o headache") for studies any more than a neurologist can climb into the mind of the radiologist who provides a vague report filled with hedges.

We really should all be more happy when patient care is at its best, and not when we are able to mislead or stump colleagues in order to engage in some adolescent academic pissing war.

Good luck.

 

[neglect]

Additionally, Neglect, if most "clinicians" were actually concerned about the best for their patients, they would take the time to write an appropriate clinical indication for the imaging they order. Good physicians will always do this.

To do otherwise is simply not in the best interest of the patient.

The clinical equivalent, I guess, would be to provide an sloppy, inaccurate "sign-out" on a patient to a covering physician. Or, to write illegible, illogical orders for the nursing staff. Or to amputate the wrong leg in surgery because one was to arrogant or hasty (to start the weekend) to actually check the chart for the agonizing 30 seconds. Or to not check on any studies that you ordered only to find that EKG that's been in the chart for three days shows diffuse ST elevations when the radiology resident discovers it.

I've seen all these in either my intern year or as a rads resident. By your logic, I should be calling for an end to internal medicine and surgery with those stories (and plenty more).

The only person hurt by these shortcuts is the patient. Plenty of sloppy physicians out there both in and out of the reading room.

Man, that sucks about the leg! What'd he say? "Sorry. I plead dyslexic." And of course you're correct. The same comes from neurology consults: ask a stupid question, get a stupid answer.

Although I don't know what "rule out headache" means (best test for this is to ask the patient. If they say no, then headache is ruled out), headache itself is a legit thing to write on the request. You have the age. Look for secondary causes of head pain. If it's from the ER, then look for SAH.

More often than not we simplify things drastically when talking to you. When getting the fellow in at night, "known shooter with fever and back pain and sensory level" works better than "wacked out addict with pneumonia from vomiting on self due to flu, who fell yesterday and now has a host of subjective complaints and an inconsistent sensory examination that may show a sensory level, but it's hard to tell."

I'm not calling for an end to radiology. But I don't think the monopoly is fair or warrented.

 

[RonaldColeman]

Man, that sucks about the leg! What'd he say? "Sorry. I plead dyslexic." And of course you're correct. The same comes from neurology consults: ask a stupid question, get a stupid answer.

Although I don't know what "rule out headache" means (best test for this is to ask the patient. If they say no, then headache is ruled out), headache itself is a legit thing to write on the request. You have the age. Look for secondary causes of head pain. If it's from the ER, then look for SAH.

More often than not we simplify things drastically when talking to you. When getting the fellow in at night, "known shooter with fever and back pain and sensory level" works better than "wacked out addict with pneumonia from vomiting on self due to flu, who fell yesterday and now has a host of subjective complaints and an inconsistent sensory examination that may show a sensory level, but it's hard to tell."
I'm not calling for an end to radiology. But I don't think the monopoly is fair or warrented.

I thought maybe my experience on my neuro rotation was atypical, but maybe neurologists are like this after all...The neurologists I have interacted with have had such rad-envy it makes me sick. They remind me of psychologists who want to prescribe psychotropics or dentists who want to do face lifts. Don't be bitter because you couldn't match in rads. I hate to be so rude--certainly there are qualified, intelligent neurologists--but I saw this mentality at every neurology site I rotated through.

 

[dongfeng41]

I thought maybe my experience on my neuro rotation was atypical, but maybe neurologists are like this after all...The neurologists I have interacted with have had such rad-envy it makes me sick. They remind me of psychologists who want to prescribe psychotropics or dentists who want to do face lifts. Don't be bitter because you couldn't match in rads. I hate to be so rude--certainly there are qualified, intelligent neurologists--but I saw this mentality at every neurology site I rotated through.

You simply think way too much of yourself and delude yourself into thinking that everybody else wants to be a radiologist. Please enlighten us as to the specific place where you saw *every* neurologist having "rad-envy" because I'm very curious to know. In all honesty, if you are a future radiologist, good for you as long as you like your chosen field. But please take your flame-baiting, arrogant attitude somewhere else, because it makes *us* sick and simply pity you.

 

[RADRULES]

Dude, the hate in your reply simply supports his point. Neurologists are a bunch of haters who wish they were smart enought to get into something else. They want to do imaging and neurointervention.... gimme a break.

Bunch of haters.

How many radiologists do you see trying to get into treating neurology patients? Speaks volumes.