How does presenting patients/cases to attending work in radiology?

[GunnerBMS]

I never did a radiology elective in medical school. I was wondering how do residents interact with attendings on cases? What is the order of things that happens?
For example:
1. Primary team orders CXR
2. Radiology resident receives order and reads patient's H&P and then reads CXR
3. Radiology resident sits down with attending and presents H&P like on IM rounds and then discusses their findings on imaging and what they would recommend to primary team

Is this basically how it works? What is the standard format for presenting cases in radiology? What exactly do residents talk about with the attendings, so that they can learn?

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[colbgw02]

I never did a radiology elective in medical school. I was wondering how do residents interact with attendings on cases? What is the order of things that happens?
For example:
1. Primary team orders CXR
2. Radiology resident receives order and reads patient's H&P and then reads CXR
3. Radiology resident sits down with attending and presents H&P like on IM rounds and then discusses their findings on imaging and what they would recommend to primary team

Is this basically how it works? What is the standard format for presenting cases in radiology? What exactly do residents talk about with the attendings, so that they can learn?

Re: Bold. Ain't nobody got no time for that. Especially for a radiograph. You'll get a brief "history" and you'll like it. In most cases, the history will actually have something to do with the thorax, to use your CXR example. If you're unlucky it will give you an ICD-10 code or, where I work, the dreaded "other".

There's a list on PACS. In the classic model, the resident prelims the exams on the list before sitting down with the attending and going through the cases. The attending points out things and makes changes, as he/she sees fit. If it's a strange or complex case, the resident and/or attending may look up the note to try to learn more information.

As the resident gains experience or if the cases are less complex (radiographs vs. MRI, e.g.), there's less in-person interaction. The resident just sends the prelim report to the attending for finalization. Most of the time the changes are cosmetic or stylistic and don't rise to the level of having a discussion.

Of course, there are hundreds of permutations to this. YMMV.

 

[qxrt]

Ain't nobody in radiology got time for rounds. It's all about the relevant clinical details and no waste-of-time review of systems for billing purposes. That is one of the many great things about this specialty. I hate inefficiency.

 

[GoPelicans]

Relevant HPI: chest pain

 

[DrfluffyMD]

We do present. They are one sentences.

Examples like “MVC with hypotension” or Left sided weakness started 4 hrs ago

 

[Cognovi]

Workflow, in ten steps:

1. Primary team orders study, providing indication/history.
2. If advanced imaging, resident reviews order and chooses protocol.
3. Study is scheduled and performed.
4. Resident reads the provided history. If the provided history smells inadequate, resident opens the chart and reads the referring provider's note, the last op note, etc.
5. Resident drafts report.
6. Attending comes over to resident workstation to read study.
7. Resident tells attending the one-liner indication based on the provided history or extract from the chart as relevant to the resident's drafted findings and impression.
8. Resident tells attending what they saw. Attending tells resident what they saw. The structure and level of detail in this step varies by attending style and stage of resident training.
9. Resident edits report and signs it off.
10. Attending returns to their own workstation, reviews resident's report, and signs it as final.

 

[CherryRedDracul]

Pretty much whatever is said above.

However, I often don't read the history before looking at the study. That keeps my pre-cognitive biases low. I call what I see objectively and then look at the history to see if the story fits or whether I should take a second look at something. Sometimes, you will get crap histories from a poorly done H&P and you'll be thrown off the trail.

 

[txguy]

The equivalent of presenting cases on rounds as an IM resident, is the "read out" session between the radiology resident and the attending. Agree with above that aint nobody got time for actual full fledged rounds with H&P, A&P, etc. The read out sessions are typically 1on1 and pretty quick, much faster than rounds on IM. This is how a radiology resident's day typically goes:

Let's say that you are a first year resident on the body rotation, reading abdomen and pelvis CTs.

1. Come in early to preview all of the abdomen and pelvis CTs on your list (inpatient performed overnight, outpatient studies left on the list, and ER studies). For each study, since you are a resident, you sometimes actually have time to get a history from the EMR software, indication for the study, etc. Most of the time you aint got time for that, and all you get is "pain" or a random CPT code a secretary put in as your entire history for every study.
2. As you go through each study, pre-dictate each them in draft mode into Powerscribe (radiology voice recognition software). Nothing is sent out to the EMR or finalized yet. (caveat: If the case is urgent/emergent you may have to put in a quick prelim or alert the primary team, sometimes after consulting with an upper level resident or attending, depending on your level of comfort).
3. Sometime mid or late morning, the attending comes by to "read out" the cases with you. They go through each case, and as they are looking at the images, you are "presenting" any history you have and your findings. This is the radiology equivalent of rounds on IM.
4. After your attending leaves and does god knows what (take a nap? check stocks? lol) you make necessary changes to the reports you already predictated, and sign them off.
5. These reports goto your attending's queue, and after they sign them off, they are finalized in the EMR and available for the clinical teams.
6. You repeat this process in the afternoon and then go home and have a beer, I mean study

 

[Radology]

Relevant HPI: chest pain

“Hey doc, this is radiology. Is your patients chest pain right or left sided?”

“Huh? He doesn’t have chest pain”

 

[loljkttyl]

There are several models of residents signing out with attendings. These vary based on the rotation you are on, what level resident you are, what attending you are working with, and which hospital/residency program you are working at. Each has pros and cons.

1) Resident previews images, drafts several reports, then reviews batches of cases when attending stops by. For radiographs, this might be around 20-40 cases. For CT, this might be around 1-5 cases. During review, attending and resident will sit side by side, with attending controlling computer with the PACS to review the images and with resident controlling computer with the dictation software to make edits to the drafted report. For each case, resident gives brief one-line history (e.g, cough) and states major findings, then attending reviews images and points out any discrepancies. If minor change, you can edit report on the fly and prelim report. If major change, you can type some notes into bottom of report, save it as a draft, then edit and prelim later, then attending reviews prelimed reports on separate computer and finalizes. This model allows for more teaching time, but attending tends to be less picky with wording of reports. As a result, attending really only has time to read impressions of reports, and only makes changes to report if major typos or errors.

2) Resident previews images, drafts and/or prelims report to attending queue. Attending reviews images and resident's preliminary reports on his/her personal workstation, makes edits, and finalizes reports. Usually the attending is sitting in the same reading room, so he/she will verbally tell you when he/she makes any major changes. This model allows for more accurate reports and is better for patient care. The attending has more time to make sure the history is correct, make sure the comparison studies are correct, and proofread the body and impression of reports for typos. The attending can review images from both current and prior/comparison studies at their own pace without feeling rushed. However, this model allows for less teaching time is probably better suited for upper level residents.

 

[tco]

My history for radiographs is usually, "I don't remember the history because I read 30 of them this morning."

Check out is more detailed for junior resident. As a senior resident, it's, "X, Y, Z (listing findings)" Then the attending agrees or disagrees and we move on.

 

[CherryRedDracul]

“Hey doc, this is radiology. Is your patients chest pain right or left sided?”

“Huh? He doesn’t have chest pain”

Like one of my senior attendings says, "The history is usually crap. Figure out what's going on objectively by looking at the images first."

 

[meister]

That’s a great idea until you pull up the scan and there’s no bladder or large bowel and different types of ostomies everywhere.