How diagnostic is diagnostic radiology?

[shadowfox87]

Ok, so I've done a lot of research and I think radiology us most likely the best fit for me. I am a former biomedical engineer and I love diagnosis i.e. I love pathology. However, I also like technology and physics, which is why I can't stick with pure pathology. I hate to say it, but I enjoy problem solving more than patient interaction. I also want to be involved in a more broad area of medicine not just one specific aspect of it, so rad onc just isn't a good fit for me. I also don't mind staying in a dark room all day since I like quiet places where I can concentrate anyways.

One thing I don't like is that I may not know what the final diagnosis of a patient is. I have too much curiosity to just look at slides one-by-one and then give my opinion without knowing what the problem was with that patient.

So can anyone please tell me - how involved is a radiologist in the pathology of a patient? Does a radiologist give his/her opinion and then just move on or are they follow-ups? Do they consult with other physicians and gather information regarding symptoms or history?

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[ad_sharp]

Ok, so I've done a lot of research and I think radiology us most likely the best fit for me. I am a former biomedical engineer and I love diagnosis i.e. I love pathology. However, I also like technology and physics, which is why I can't stick with pure pathology. I hate to say it, but I enjoy problem solving more than patient interaction. I also want to be involved in a more broad area of medicine not just one specific aspect of it, so rad onc just isn't a good fit for me. I also don't mind staying in a dark room all day since I like quiet places where I can concentrate anyways.

One thing I don't like is that I may not know what the final diagnosis of a patient is. I have too much curiosity to just look at slides one-by-one and then give my opinion without knowing what the problem was with that patient.

So can anyone please tell me - how involved is a radiologist in the pathology of a patient? Does a radiologist give his/her opinion and then just move on or are they follow-ups? Do they consult with other physicians and gather information regarding symptoms or history?

I think it varies by Radiologist and institution. As for myself (I am a PGY-3, R2), I follow up on a lot of my patients to see what happens to them after I read an initial diagnostic study. I read the op notes / pathology / labs, etc. Additionally, I make a lot of phone calls for clarification and to ask about clinical status of the the patients to optomize study protocols and answer specific questions. As for interaction with pathology, we have several dialy or weekly meetings with pathology at my institution (especially in MSK and chest) where we come to consensus opinions about final pathology reports. This is not the norm everywhere, but more and more, I think things may head in this direction. Addionally, call experiences are great for being VERY involved in patient care and interacting with clinicians / answering their questions, etc. I think that my experience is fairly typical of residents in training as well as most board-certified radiologists. I love it. I really feel like I make a bigger difference to patients doing this than I would in any other field of medicine because I enjoy it so much. Your best bet is to spend a lot of time in the reading room to make sure that you're confortable with it.

To further answer your question about our role in pathology-I think about it like this: The pathologists are fantastic at the microscopic description of disease and disease classifications. Our role lies more in the "big picture" realm of disease. We define macroscopic disease, stage disease preoperatively / monitor postoperatively, help with surgical planning, aid with treatment decision making, limit differentials, determine disease severity/ extent, etc. Aside from that, there is a wide range of interventional / procedural aspects to Radiology that I really enjoy. Despite what I thought before entering residency, it is a very wide field as far as possible practice models that will allow as much (or little) patient contact as you'd like.

 

[shadowfox87]

Thank you for your response. Yea that sounds good. As long as I'm involved in the differential diagnosis somehow, I'm happy. As for patient care, I'm sure there are other experts better qualified for that, I just want to help with diagnosis and treatment.

 

[colbgw02]

A lot will depend on your EMR. It's very difficult for me to get any information other than just lab results on patients, but there are plenty of places where the opposite is true. You can always get follow-up if you dig hard enough, but some places require more digging than others.

I'm skeptical that the experiences of residents in the academic world mirror that of private practice radiology. In academia, there are tumor boards, conferences, and residents in house after hours. In private practice, such conferences don't necessarily exist, and the after-hours radiologist is just as likely to be in a different state. Also, the workload of private practice radiology can be oppressive, so a radiologist is that much less likely to follow-up on things.

 

[jake2]

I take note of interesting cases and check up on them later. This is not a required part of the job, but it is interesting to do when you feel like it. We have a pretty good EMR which makes it pretty easy as well.

The amount of information you have about a patient varies from situation to situation. Every plain film from our ED or ICU's is supposedly for cough on the requisition (including MSK films funnily enough), but it's pretty easy to dig in the EMR and get more information. You can call people if you really need a piece of information, but this tends to be a hassle.

Sometimes, disease entities have characteristic imaging findings and we can come down hard on a diagnosis (of course that is a Juvenile Nasopharyngeal Angiofibroma, what else could it be?!). Sometimes, we don't have much to add at all (very hard to diagnose hyerkalemia on a CT). I feel like most of the time, though, we sort out the big picture problem and leave the exact differentiation to the pathologists.

The chain goes something like this:
ED: "Patient has belly pain. Needs belly CT"
Radiology: "Well she has an ovarian mass that may or may not be causing the pain, but she should get that checked out. Looks malignant"
Path: "It's a serous cystadenocarcinoma"

So we pin down the broad details of what's going on, though the exact differentiation usually falls to the path guys. At least that's how it usually seems to work out to me...

 

[Enkidu]

This is a great thread. My interest is in pathology, but I also envy the ability of radiology to make a huge difference in an acute illness, even if they don't quite nail the diagnosis. Pathology makes the definitive diagnosis, but it often comes after the patients lesion has been resected. Of course, this is still the major determiner of the subsequent care that they will receive, but it is anything but rapid.

 

[tum]

This is an active topic of discussion in radiology. As a resident, as long as you're at a decent program, you will get to go to something called the AIRP (formerly AFIP) in DC -- a month long radiology-pathology correlation course.

You spend that month looking at cases along with their histologic and gross correlative images. It is a phenomenal experience and what some would argue is the purest way of improving one's diagnostic skills.

Any good pathologist will tell you there are certain diagnoses that change from malignant to benign in the setting of different radiologic findings (ie. bone tumors). Or for example in mammography, times when a biopsy comes back as negative, but the appearance of the lesion is so dangerously spiculated, the patient goes for mastectomy regardless. The line between radiology and pathology is often blurred.

In my opinion, radiology is the ultimate diagnostic specialty. Physical exam has become an antiquated notion. With the increasingly rapid pace of medicine, history taking is in shambles.

Many of the scans I read in the ER, for example, are based on one line histories taken by an admitting nurse. And frankly, I can't really tell the difference between that and the resident/attending histories. They're all uniformly rushed and inadequate.

One thing that made me choose radiology over diagnostic specialties was the realization that the vast majority of time in medicine, the diagnosis is made in the scanner gantry.

 

[Enkidu]

In my opinion, radiology is the ultimate diagnostic specialty. Physical exam has become an antiquated notion. With the increasingly rapid pace of medicine, history taking is in shambles.

In what sense do you mean ultimate? I guess in the normal sense of the word, pathology provides the ultimate diagnosis.

Do you mean that radiology is a diagnostic specialty and it is "ultimate" in the sense that it is just more awesome than the other specialties?

Incidentally, when a breast lesion is benign by biopsy but spiculated on imaging, what is the interpretation? Is it that the biopsy missed the malignant tissue, or is it that the spiculated appearance is somehow prognostic of a lesion that is currently benign but will become malignant?

 

[colbgw02]

Incidentally, when a breast lesion is benign by biopsy but spiculated on imaging, what is the interpretation? Is it that the biopsy missed the malignant tissue, or is it that the spiculated appearance is somehow prognostic of a lesion that is currently benign but will become malignant?

The former. Rad/path discordance is an indication for a repeat biopsy, usually an excisional one.