Helpful Hints for Radiologists

[sievert_fever]

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!

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[doc05]

Pretty much impossible to generalize. ask the surgeons in your hospital.

 

[Gastrapathy]

Not a surgeon but here are my least favorites:

please don't call "misty mesentery, cannot rule out mesenteric panniculitis" on half your CTs. That rabbit hole never leads anywhere.

"nonspecific jejunal thickening without surrounding inflammatory changes, cannot rule out Crohns" is terrible. Peristalsis is not a finding.

"Mild biliary and pancreatic dilation, cannot rule out occult neoplasm" when you don't see a mass. That might have been valid back with an 8 slice scanner but not anymore old-timer.

 

[vhawk]

Not a surgeon but here are my least favorites:

please don't call "misty mesentery, cannot rule out mesenteric panniculitis" on half your CTs. That rabbit hole never leads anywhere.

"nonspecific jejunal thickening without surrounding inflammatory changes, cannot rule out Crohns" is terrible. Peristalsis is not a finding.

"Mild biliary and pancreatic dilation, cannot rule out occult neoplasm" when you don't see a mass. That might have been valid back with an 8 slice scanner but not anymore old-timer.

Not sure I agree with the last one. Probably close to 10% of my panc cancers are occult on CT, and in those cases it's only the secondary findings of dilated duct etc that increase suspicion and lead to diagnosis. Obviously the word "mild" is doing a lot of work in your sentence but I don't know that every PCP is aware of the significance of a double duct sign.

Definitely some selection bias here as the ones that I see have been filtered through you first so I'm sure you see far more of these that end up being nothing.

 

[Diagnostic Laparotomy]

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!

Not every noncon CT with a minute change in bowel diameter should be read as "cannot rule out small bowel obstruction."

 

[Gastrapathy]

10%????? Then there’s something wrong with your radiologists or there’s something I’m missing. Mayo published a series with zero occult cancers last year. Normal liver tests and high quality cross sectional imaging with no mass just isn’t a mass.

I refer ~25 surgical pancreas cancers/year and can remember one mass that wasn’t visible on CT (or EUS but I needled where the BD cut off and got cancer). But she was jaundiced. The mass was visible on MRI. I’ll have to look to see what happened to her.

 

[DoctwoB]

Stop telling me to “consider cystoscopy” on every male patient with a thick bladder wall.

 

[Wordead]

Fluid in the mastoid is not "mastoiditis". Please do not call it such.

 

[vhawk]

10%????? Then there’s something wrong with your radiologists or there’s something I’m missing. Mayo published a series with zero occult cancers last year. Normal liver tests and high quality cross sectional imaging with no mass just isn’t a mass.

I refer ~25 surgical pancreas cancers/year and can remember one mass that wasn’t visible on CT (or EUS but I needled where the BD cut off and got cancer). But she was jaundiced. The mass was visible on MRI. I’ll have to look to see what happened to her.

I'm whippling a guy next week with no mass but bx proven adeno and I've got a guy getting neoadjuvant right now with no mass who has a peri portal LN that was what confirmed the diagnosis. My sample size isn't big enough to say 10% with any confidence but it is certainly not exceedingly rare to have a panc cancer with no obvious mass on CT. Publ8shed sensitivity for contrast CT is 76-92%.

Don't think it's fair to include lesions later found on mri or eus since that is presumably exactly what the radiologist is suggesting

 

[LucidSplash]

Do not call me 90% of the time I order a study and ask me if I really want the study I ordered OR don’t I want a different study that I didn’t order instead OR isn’t the study from 2 weeks/months ago enough for operative planning OR try to block my emergent CTA on the suspected ruptured AAA because of a creatinine of 1.5.

This isn’t radiology everywhere as I didn’t get any near this much push back on imaging where I did residency. But that place did not have radiology residents. The residents here seem to believe it is there mission in life to tell me I don’t actually need the studies I order.

 

[startswithb]

Please do not suggest laboratory tests for correlation. "Correlate with urinalysis," for thickened bladder or the worst that I have seen, "enlarged prostate, correlate with PSA." UA and PSA can be ordered in the appropriate clinical setting which does not occur in a vacuum with non-specific radiologic findings. I worry that a PCP or ER doc could order a PSA in a 75+ year old with BPH who ends up with an unnecessary biopsy at worst or even just an unnecessary urology appointment and needless worry.

 

[Pir8DeacDoc]

Fluid in the mastoid is not "mastoiditis". Please do not call it such.

You totally beat me to this one. I was ready to post the same thing

 

[Jolie South]

Do not call me 90% of the time I order a study and ask me if I really want the study I ordered OR don’t I want a different study that I didn’t order instead OR isn’t the study from 2 weeks/months ago enough for operative planning OR try to block my emergent CTA on the suspected ruptured AAA because of a creatinine of 1.5.

This isn’t radiology everywhere as I didn’t get any near this much push back on imaging where I did residency. But that place did not have radiology residents. The residents here seem to believe it is there mission in life to tell me I don’t actually need the studies I order.

Kidneys don’t matter if you’re dead from a ruptured AAA. Just sayin’.

 

[DoctwoB]

Please do not suggest laboratory tests for correlation. "Correlate with urinalysis," for thickened bladder or the worst that I have seen, "enlarged prostate, correlate with PSA." UA and PSA can be ordered in the appropriate clinical setting which does not occur in a vacuum with non-specific radiologic findings. I worry that a PCP or ER doc could order a PSA in a 75+ year old with BPH who ends up with an unnecessary biopsy at worst or even just an unnecessary urology appointment and needless worry.

Likewise you need to know that patients can and will read your report. So when you write that you “can’t rule out X cancer” you may have just scared the **** out of said patient and generated unnecessary phone calls and clinic visits. If the study is indeterminant for something it is actually ordered for then that may be appropriate, but when you write “thickened bladder wall, likely cystitis or due to bladder outlet obstruction, can’t rule out malignancy,” well of course you can’t rule it out because CT is a cr*p test to look for bladder cancer.

 

[LucidSplash]

Kidneys don’t matter if you’re dead from a ruptured AAA. Just sayin’.

Tried to explain that. Ultimately had to have the chair of the department call them. At which point everyone from tech to resident to attending denied having blocked the CTA.

Oh and they also give me the hardest time about get CTAs on ESRD/HD patients unless they are going to dialyze later that day. Some fear about contrast causing severe fluid shifts to the point that we have to promise to send someone for extra HD even if they don't otherwise need it just to get a CTA. Its nutso.

 

[Jolie South]

Tried to explain that. Ultimately had to have the chair of the department call them. At which point everyone from tech to resident to attending denied having blocked the CTA.

Oh and they also give me the hardest time about get CTAs on ESRD/HD patients unless they are going to dialyze later that day. Some fear about contrast causing severe fluid shifts to the point that we have to promise to send someone for extra HD even if they don't otherwise need it just to get a CTA. Its nutso.

My attendings are like “Fine, but I need you to document in the chart why you can’t do this.” 5 seconds after hanging up the phone, we hear them call the patient down.

And I have yet to see these “fluid shifts”. We always do a courtesy call to nephrology and they never dialyze the patient until the next day anyways.

Worked well also on CT when we had bleeding after coming off bypass and attending calling and asking for Kcentra. Pharmacy says we can’t get it. Attending says same thing over speakerphone in OR and kcentra magically arrives.

 

[LucidSplash]

My attendings are like “Fine, but I need you to document in the chart why you can’t do this.” 5 seconds after hanging up the phone, we hear them call the patient down.

And I have yet to see these “fluid shifts”. We always do a courtesy call to nephrology and they never dialyze the patient until the next day anyways.

Worked well also on CT when we had bleeding after coming off bypass and attending calling and asking for Kcentra. Pharmacy says we can’t get it. Attending says same thing over speakerphone in OR and kcentra magically arrives.

I’ve given up trying to explain my reasoning for wanting X study. Now when they question it I repeat the indication I gave in the order and say “Dr. [high-profile Attending] told me order it this way.” Like magic, all objections cease. Which tells me that they are just trying to power play me for no good reason, because if there was a serious concern that their attendings would back them up for, they wouldn’t capitulate to “Vascular attending said so.”

That doesn’t stop me from wanting to reach through the phone and rip someone’s throat out every time I get one of these pages.

Fellowship is making me an angry person.

 

[Jolie South]

I’ve given up trying to explain my reasoning for wanting X study. Now when they question it I repeat the indication I gave in the order and say “Dr. [high-profile Attending] told me order it this way.” Like magic, all objections cease. Which tells me that they are just trying to power play me for no good reason, because if there was a serious concern that their attendings would back them up for, they wouldn’t capitulate to “Vascular attending said so.”

That doesn’t stop me from wanting to reach through the phone and rip someone’s throat out every time I get one of these pages.

Fellowship is making me an angry person.

I am lucky to have several layers of residents and mid levels between me and people that give us this BS.

 

[akwho]

Everytime you ask ortho why we are ordering an advance imaging study, the answer is bone broken, need seeing to fix good.

You guys are pretty alright though and we appreciate you not giving us a hard time.

 

[dpmd]

If you see the small bowel is dilated uniformly up to the cecum and the colon is then uniformly full of **** please report that little tidbit instead of calling it a small bowel obstruction. Fecal impaction backing up into the small bowel is not something that can usually be managed by medicine without them needing to call me in the middle of the night (or at all really). Also helpful to report a colon stuffed full of **** when the appendix is borderline in size without surrounding inflammation. Even if they don't give you the patient history of abdominal pain for a week and the normal white blood count entertaining the possibility that the appendix is just also full of **** will help avoid another late night consult due to your reading of acute appendicitis and then I have to explain to every person remotely involved with the patient why I don't think an operation is needed. Basically anytime there is a lot of **** just mention it. You don't have to diagnose it as constipation or impaction. Just clue the other docs in that maybe cleaning out the **** might fix the patient.

 

[kitsunepixie]

If you see the small bowel is dilated uniformly up to the cecum and the colon is then uniformly full of **** please report that little tidbit instead of calling it a small bowel obstruction. Fecal impaction backing up into the small bowel is not something that can usually be managed by medicine without them needing to call me in the middle of the night (or at all really). Also helpful to report a colon stuffed full of **** when the appendix is borderline in size without surrounding inflammation. Even if they don't give you the patient history of abdominal pain for a week and the normal white blood count entertaining the possibility that the appendix is just also full of **** will help avoid another late night consult due to your reading of acute appendicitis and then I have to explain to every person remotely involved with the patient why I don't think an operation is needed. Basically anytime there is a lot of **** just mention it. You don't have to diagnose it as constipation or impaction. Just clue the other docs in that maybe cleaning out the **** might fix the patient.

This includes on shunt series. I often see a lot of **** on shunt series. Many times the stool burden isn't mentioned in the report and can be a major issue for shunt kids, especially ones with myelomeningocele.

 

[dpmd]

This includes on shunt series. I often see a lot of **** on shunt series. Many times the stool burden isn't mentioned in the report and can be a major issue for shunt kids, especially ones with myelomeningocele.

And lots of docs don't look at the films themselves so no one else will catch it (have had to operate on people whose impaction was so severe they perfed their colon)

 

[Winged Scapula]

1) don’t tell me what operation to do; your clinical input is not appreciated

2) when doing a mammogram on a woman with ****loads of seborrheic keratosis, put stickers over the skin lesion (this is more for the tech than you)

3) I don’t care how good your US tech is, if I’m ordering an outpatient diagnostic study (ie, done between 8 and 5), I expect you to do the study yourself

4) As mentioned above, if you disagree with what Ivde ordered don’t a) tell the patient I’ve sent to you and b) don’t just decide not to do it without a courtesy call to discuss it with me.

5) more important than what is in your report (especially for those of us who read our own studies) is how you and your techs interact with the patients: learn some compassion, empathy, learn your role (it’s not to discuss treatment) and don’t throw your colleagues under the bus. Even if you think we suck you should tell the patient that we’re the best because that's what I tell them about you, even if its not true.

6) stay in your lane; lots of radiology facilities here started doing genetic testing for high risk patients. A revenue stream I had to assume. Problem? What happens when you get a positive result? You have no idea what to tell the patient and now they are stuck with a result and a wait to get into to see someone to tell them what the appropriate management is.

Interestingly enough, after the uproar here locally from clinicians, they have quietly stopped doing the testing.

7) standard of care is to correlate with any associated, prior studies. I don't appreciate it when the PET/CT says, "possible malignancy, consider biopsy" of the primary site when the patient has already been biopsied, has a malignant diagnosis and you have all the prior studies and my ICD10 coding reflecting the diagnosis. Looks sloppy as I ain't ordering a PET for the heck of it.

8) speaking of sloppy, please review your dictated reports for glaring errors. I get it, we all make mistakes. But patients read these reports and if you're saying right and you mean left, cm instead of mm, or there is some unintelligible garbage in there, it again looks sloppy and makes patients think you don't know what you're talking about.

 

[deleted547339]

Don’t suggest consults or interventions. If we assume you are competent to read the image, you should assume we are competent to put the results into the clinical context. If someone has a bad outcome and we don’t do exactly what you said (whether appropriate or not), that’s a fodder for a lawsuit.

Don’t ask if we “really want a study” unless it is technically the wrong study to answer the question we are asking. If I order a test, it’s because I think there may be a diagnosis x, y or z. Now, if you think an MR is a better choice than CT to evaluate for that diagnosis, that’s one thing. But don’t tell me what is and isn’t indicated otherwise I will ask you to come and examine the patient and document why you won’t do the test that the primary physician deems necessary.

Don’t addend your read with significant findings without calling someone.

Don’t call the ER doc to discuss missed findings on a patient that is already upstairs. With EMRs, it should only take 10 seconds to figure out what floor they are on and to whom they are admitted.

Don’t say “clinical correlation required” on everything. We know.

Be as definitive as you can.

 

[Winged Scapula]

Don’t suggest consults or interventions. If we assume you are competent to read the image, you should assume we are competent to put the results into the clinical context. If someone has a bad outcome and we don’t do exactly what you said (whether appropriate or not), that’s a fodder for a lawsuit.

Don’t ask if we “really want a study” unless it is technically the wrong study to answer the question we are asking. If I order a test, it’s because I think there may be a diagnosis x, y or z. Now, if you think an MR is a better choice than CT to evaluate for that diagnosis, that’s one thing. But don’t tell me what is and isn’t indicated otherwise I will ask you to come and examine the patient and document why you won’t do the test that the primary physician deems necessary.

Don’t addend your read with significant findings without calling someone.

Don’t call the ER doc to discuss missed findings on a patient that is already upstairs. With EMRs, it should only take 10 seconds to figure out what floor they are on and to whom they are admitted.

Don’t say “clinical correlation required” on everything. We know.

Be as definitive as you can.

OMG...the surprise addendum, or the addendum you never get. Yes!!!

Also, if doing 2 studies on the same patient on the same day, don't combine them into one report and finish the impression with "everything fine" (because one study was but the other wasn't). I cannot tell you how many times a PCP read a report which stated "Birads 1" for a breast sonogram, but Birads 4 for the mammogram and missed the latter because the last line of the impression was about the normal sonogram. Yes, this was their mistake but why not make it easier for these overworked colleagues and make the badness very very very obvious? We have one hospital here who is notorious for that so I have to read those reports extra carefully.

 

[Dr.LeoSpaceman]

Don’t suggest consults or interventions. If we assume you are competent to read the image, you should assume we are competent to put the results into the clinical context. If someone has a bad outcome and we don’t do exactly what you said (whether appropriate or not), that’s a fodder for a lawsuit.

Just had this one the other day. Person with a previously infected wound, actively being packed and healing well. Gets a CT scan that is read as something like "Inflammation and scarring above rectus muscle, concern for infection. Consider surgical debridement." This of course generates an unnecessary ER visit and surgical consult. Brutal.

Don’t call the ER doc to discuss missed findings on a patient that is already upstairs. With EMRs, it should only take 10 seconds to figure out what floor they are on and to whom they are admitted.

OMG...the surprise addendum, or the addendum you never get. Yes!!!

At one of our hospitals there is a nighthawk notorious for calling the ED and giving a verbal prelim read, and then the person dictating the final report the next day reads something materially different.

 

[Apollyon]

At one of our hospitals there is a nighthawk notorious for calling the ED and giving a verbal prelim read, and then the person dictating the final report the next day reads something materially different.

You should be able to direct that that person not read for you. Although I am not familiar with all telerads companies, the ones with which I have worked have all had a QI program, where misses would be reviewed. There have been a few doozies that have totally sucked, and we got them bounced.

 

[Smurfette]

A lot of these things are universal...I find myself going "oh yeah, that is a problem" quite a bit in this thread.

1. If you are a large radiology group, please make it easier for me to know how to reach the reading radiologist, especially for ER reads. A 1-800 number where they can then redirect the call is unhelpful when said number is only staffed 8-4:30 (when I can just call or stop by the right place anyhow, and don't need the 1-800 #) and the reports don't give an after hours contact number. (the hospital system I work for has a couple people working all night, but could be physically at any of 5 hospitals, each of which has a few reading room locations).

2. The combo mammo and US reads drive me a bit crazy too---our breast radiologists tend to blend the descriptions enough that it takes careful reading to figure out which line is about the mammo and which is about the US.

3. Please stop putting "suspicious for cholecystitis" on abdominal US reports when the only "finding" is a tech-reported "positive sonographic Murphy's sign". If they don't have pericholecystic fluid, gallbladder wall thickening or any other obvious gallbladder or biliary pathology, I'm guessing the tech was pushing pretty hard to find the gallbladder cuz the patient was obese and got uncomfortable during the struggle to find the structures. The ER call to me inevitably starts with "I was going to send the patient home but...".

 

[DrfluffyMD]

Do not call me 90% of the time I order a study and ask me if I really want the study I ordered OR don’t I want a different study that I didn’t order instead OR isn’t the study from 2 weeks/months ago enough for operative planning OR try to block my emergent CTA on the suspected ruptured AAA because of a creatinine of 1.5.

This isn’t radiology everywhere as I didn’t get any near this much push back on imaging where I did residency. But that place did not have radiology residents. The residents here seem to believe it is there mission in life to tell me I don’t actually need the studies I order.

I don’t try to fight inappropriate studies anymore. It’s honestly faster to read them and generate RVU than to hold up the list. Everyone is happy except the patient who got inappropriate radiation and another bill....

There are definitely problems from both sides, inappropriate studies and inappropriate blocks.

 

[dr zaius]

This thread makes me realize our radiology department is pretty decent. Aside from the occasional consult suggestions (diffuse bladder wall thickening in a patient with cystitis, please do not suggest urology consultation for direct visualization) and call for "vas-itis" in a patient with an inguinal hernia and stranding around the cord they do a pretty decent job. I have never had them make an addendum and fail to notify.

 

[Donald Juan]

I’ve given up trying to explain my reasoning for wanting X study. Now when they question it I repeat the indication I gave in the order and say “Dr. [high-profile Attending] told me order it this way.” Like magic, all objections cease. Which tells me that they are just trying to power play me for no good reason, because if there was a serious concern that their attendings would back them up for, they wouldn’t capitulate to “Vascular attending said so.”

That doesn’t stop me from wanting to reach through the phone and rip someone’s throat out every time I get one of these pages.

Fellowship is making me an angry person.

I like to ask the radiology resident who's getting pushy with recommendations to go see the pt and write their official recommendations in their consult note. They never take me up on it.

 

[DrfluffyMD]

I like to ask the radiology resident who's getting pushy with recommendations to go see the pt and write their official recommendations in their consult note. They never take me up on it.

We could, then we would get push back about overstepping our bounds.

Surgical services usually aren’t culprit of this, but there are many, many times when people use imaging to substitute for physical exams.

 

[vhawk]

We could, then we would get push back about overstepping our bounds.

Surgical services usually aren’t culprit of this, but there are many, many times when people use imaging to substitute for physical exams.

I can't say I've never been guilty of this. 2am, the intern calls me and says "exam is benign do you want me to scan him?" and although the scan is technically indicated it's certainly conceivable that if a chief had called (or I was there examining the patient) I'd have held off. This is never the first thought on my mind but I'm human and I'm sure there have been borderline situations where it pushes me over.

If I was someone who had very little confidence in their exam then this would weigh on my decisions every single time and I'd probably routinely be someone who you are talking about.

 

[deleted547339]

We could, then we would get push back about overstepping our bounds.

Surgical services usually aren’t culprit of this, but there are many, many times when people use imaging to substitute for physical exams.

Sure, you can’t omit the physical exam, but physical exam has limitations like any other test with sensitivities and specificities. Because it has classically been so revered in medical education, we don’t often get taught to look at it that way. And when it comes to missing life ending diagnoses, the sensitivity of physical exam is often times not adequate.

 

[DrfluffyMD]

Sure, you can’t omit the physical exam, but physical exam has limitations like any other test with sensitivities and specificities. Because it has classically been so revered in medical education, we don’t often get taught to look at it that way. And when it comes to missing life ending diagnoses, the sensitivity of physical exam is often times not adequate.

I agree. The sensitivity and specificity of imaging is much higher and that’s why I do not push back against studies.

 

[meister]

Haha this thread is funny.

 

[meister]

I refuse to believe someone recommended surgical debridement.

 

[deleted547339]

I refuse to believe someone recommended surgical debridement.

Seriously? I’ve seen that more than once.

 

[meister]

 

[Winged Scapula]

I refuse to believe someone recommended surgical debridement.

Why?

Radiologists recommend clinical management all the time.

 

[scootad.]

I’m a radiologist. Sometimes I recommend specific clinical management. It depends on who is ordering it. If it’s a PA, mid level or FP who I know isn’t up to par with current management I will be quite specific in recommending Gyn Onc consultation for large complex cystic mass in postmenopausal pt (or direct visualization for endometrial thickening in post meno women). If it’s a surgeon/specialist ordering the study (or the history makes it obvious said specialist is already following pt) I’m not as specific in my reccs.

A good radiologist tailors their reports to the audience.

 

[scootad.]

You’d be surprised at the suboptimal medicine being practiced out in the community. I’ve seen too many things fall through the cracks (“indeterminate renal masses” never getting followed up until cancer spread everywhere) etc. Yes, as Rads we need to call in these results but radiology practiced in 2018 where many rads are reading 150+ cases a day, adding a specific consult (in the righ setting) to the report helps adds a barrier of protection. Some PCPs need the hand holding.

 

[cpants]

Stop suggesting additional imaging studies in the report. Usually, renal mass studies generate this situation.

US shows renal mass -- rads suggests CT -- CT shows renal mass -- Consider MRI -- MRI shows renal mass -- suggest repeat ultrasound. Many times the PCP's have ordered all of these before I end up seeing the patient.

 

[TraumaLlamaMD]

You’d be surprised at the suboptimal medicine being practiced out in the community. I’ve seen too many things fall through the cracks (“indeterminate renal masses” never getting followed up until cancer spread everywhere) etc. Yes, as Rads we need to call in these results but radiology practiced in 2018 where many rads are reading 150+ cases a day, adding a specific consult (in the righ setting) to the report helps adds a barrier of protection. Some PCPs need the hand holding.

In this case can we also request similar hand-holding when no intervention is needed - incidental epiploic appendagitis comes to mind? “A small area of inflammation consistent with epiploic appendagitis is noted, please do not consult surgery”

On a more serious note, I’ve had a few reads over the past week or two that I very much appreciated. “No radiographic evidence of small bowel obstruction,” etc - took a stance, answered the clinical question that prompted the study, may have saved the patient an intervention or two depending on who ordered the study and why.

 

[Dr.LeoSpaceman]

“No radiographic evidence of small bowel obstruction,” etc - took a stance, answered the clinical question that prompted the study, may have saved the patient an intervention or two depending on who ordered the study and why.

Definitely prefer this one to "Borderline small bowel dilatation without transition point, cannot exclude obstruction." Though realistically the problem is not with this read. It's the provider on the other side evaluating a patient with no clinical signs of obstruction and this read, but pings me for a "r/o SBO" consult anyway.

 

[meister]

Why?

Radiologists recommend clinical management all the time.

I would never recommend a specific surgical procedure. Particularly debridement, the indications for which are determined almost entirely by direct visualization/examination. "Big brain mass. Recommend resection." Like, wtf? My tumor boards would be never ending sh*tstorms if that kind of crap was in all the reports.

Big difference between that and telling the FP that yeah, that pelvic/renal mass needs to see a specialist. Or all the other random detritus that finds its way into radiology reports primarily as CYA.

 

[Winged Scapula]

I would never recommend a specific surgical procedure. Particularly debridement, the indications for which are determined almost entirely by direct visualization/examination. "Big brain mass. Recommend resection." Like, wtf? My tumor boards would be never ending sh*tstorms if that kind of crap was in all the reports.

Big difference between that and telling the FP that yeah, that pelvic/renal mass needs to see a specialist. Or all the other random detritus that finds its way into radiology reports primarily as CYA.

Yes but we’re not talking about you.

Upstream where it’s mentioned that clinical management is tailored to the audience I have no issue with someone recommending a Specific consult especially if the study was ordered by a mid-level.

What I object to is the radiologist actually mentioning the type of surgery that should be done :that’s veering way out of your lane and you have colleagues who do it.

 

[IJL]

Interesting thread. There are some bad radiologists out there (just like in every other specialty, including surgery).

Not a surgeon but here are my least favorites:

please don't call "misty mesentery, cannot rule out mesenteric panniculitis" on half your CTs. That rabbit hole never leads anywhere.

"nonspecific jejunal thickening without surrounding inflammatory changes, cannot rule out Crohns" is terrible. Peristalsis is not a finding.

"Mild biliary and pancreatic dilation, cannot rule out occult neoplasm" when you don't see a mass. That might have been valid back with an 8 slice scanner but not anymore old-timer.

If I see true misty mesentery, then I'm calling it, and mentioning it in my impression. I usually say it's a nonspecific thing, could be sclerosing mesenteritis, etc., and then recommend a follow up CT. It could be lymphoma, so why wouldn't you get a follow up? With that said, I don't see real misty mesentery that often.

In this case can we also request similar hand-holding when no intervention is needed - incidental epiploic appendagitis comes to mind? “A small area of inflammation consistent with epiploic appendagitis is noted, please do not consult surgery”

In residency, most of the ED residents (and some attendings) had never heard of epiploic appendigitis. So that diagnosis usually resulted in a phone call and I would specifically tell them to NOT consult surgery for that finding.

Yes but we’re not talking about you.

Upstream where it’s mentioned that clinical management is tailored to the audience I have no issue with someone recommending a Specific consult especially if the study was ordered by a mid-level.

What I object to is the radiologist actually mentioning the type of surgery that should be done :that’s veering way out of your lane and you have colleagues who do it.

Yeah that seems crazy, you have any other specific instances?

Usually the most I'll say is something like "consider x, y, or z consult." again, particularly dealing with midlevels or family medicine.

 

[Winged Scapula]

Interesting thread. There are some bad radiologists out there (just like in every other specialty, including surgery).



If I see true misty mesentery, then I'm calling it, and mentioning it in my impression. I usually say it's a nonspecific thing, could be sclerosing mesenteritis, etc., and then recommend a follow up CT. It could be lymphoma, so why wouldn't you get a follow up? With that said, I don't see real misty mesentery that often.



In residency, most of the ED residents (and some attendings) had never heard of epiploic appendigitis. So that diagnosis usually resulted in a phone call and I would specifically tell them to NOT consult surgery for that finding.



Yeah that seems crazy, you have any other specific instances?

Usually the most I'll say is something like "consider x, y, or z consult." again, particularly dealing with midlevels or family medicine.

Yep.


"No evidence of multicentric or contralateral disease. Area of abnormal enhancement surrounding clip artifact from known malignancy measures 7 mm; consider localized lumpectomy and sentinel node biopsy" (study ordered by surgeon)

"Using the Tyrer-Cusick Risk Model, her lifetime risk of breast malignancy is 37.5%. Given the complex imaging findings, Category D dense breasts and lifetime risk, consider bilateral mastectomy with or without reconstruction for risk management".

These are just a couple from the last year; if I scanned my reports I could find many many more (albeit its mostly 2 local radiologists who are the worst offenders).

 

[IJL]

Yep.


"No evidence of multicentric or contralateral disease. Area of abnormal enhancement surrounding clip artifact from known malignancy measures 7 mm; consider localized lumpectomy and sentinel node biopsy" (study ordered by surgeon)

"Using the Tyrer-Cusick Risk Model, her lifetime risk of breast malignancy is 37.5%. Given the complex imaging findings, Category D dense breasts and lifetime risk, consider bilateral mastectomy with or without reconstruction for risk management".

These are just a couple from the last year; if I scanned my reports I could find many many more (albeit its mostly 2 local radiologists who are the worst offenders).

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.