How good do physicians have to be at reading imaging (eg CT, MRI)?

[Hemichordate]

Do they have to be pros at it, or do they just need to know the bare minimum to interpret the image?

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[FSU2013]

Almost every image will be read by a radiologist, but it's certainly field dependent.

If you do IM or FM, you could probably never look at an X-ray. A lot of orthopods have x-ray machines in the office, some ENTs have small CTs that can scan the head, a lot of docs in the ED will start treatment or decide dispo before the official read, radiation oncologists use images in treatment planning.

 

[Doctor D]

If waiting on urgent findings such as in the ER, you better not miss the pneumothorax or other acute diagnosis. Radiologists are the doctors who are best suited to review diagnostic images and do in almost all cases. Best field of medicine in my biased opinion.

 

[mimelim]

If you go into surgery, you will read all of your own films. You will always check for radiology reads and will end up developing a relationship with your radiologist from discussions about films.

At the end of the day, you need to be able to read your own films because you are constantly coorelating the anatomy on the screen to the anatomy in front of you. If you can't read the imaging, you will always have less information than your colleagues when approaching cases.

 

[VenusinFurs]

If you do IM or FM, you could probably never look at an X-ray.

I disagree. There are often situations where you need to evaluate x ray findings fairly quickly (does that guy in the ER look like he has pneumonia? Does your lady in the ICU look like she has an infiltrate in her lungs, or is it fluid, or ARDS?) and you can't wait around on the radiology read. Also, while you're in training, if you don't cast even a cursory glance at the imaging and vomit out some kind of opinion on what's going on you're going to get in trouble. Also there's always a chance that the wrong read was sent to your patient's chart so you have to double check that what the radiologist is saying makes sense.

So yeah you don't have to be a pro but you do have to at least try.

 

[link2swim06]

I disagree. There are often situations where you need to evaluate x ray findings fairly quickly (does that guy in the ER look like he has pneumonia? Does your lady in the ICU look like she has an infiltrate in her lungs, or is it fluid, or ARDS?) and you can't wait around on the radiology read. Also, while you're in training, if you don't cast even a cursory glance at the imaging and vomit out some kind of opinion on what's going on you're going to get in trouble. Also there's always a chance that the wrong read was sent to your patient's chart so you have to double check that what the radiologist is saying makes sense.

So yeah you don't have to be a pro but you do have to at least try.

+1. IM better at least be able to read a cxr and chest CT...they will never be the final read, but should be able to put the wheels into motion to treat obvious findings before radiology has their say (at least that is what i saw during my IM rotation).

 

[Vano]

Always try to look at your pt's films, like the rest of us radiologists miss things or put them in reads incorrectly, and it's just good to be able to call things yourself and initiate treatment or call a radiologist to speed up the read if you see something concerning but can't quite figure it out.

 

[mimelim]

Always try to look at your pt's films, like the rest of us radiologists miss things or put them in reads incorrectly, and it's just good to be able to call things yourself and initiate treatment or call a radiologist to speed up the read if you see something concerning but can't quite figure it out.

Never mind that the radiologist hasn't seen the patient and is essentially flying blind. You have the advantage of seeing the patient first hand to clinically coorelate things.

 

[ArcGurren]

Almost every image will be read by a radiologist, but it's certainly field dependent.

If you do IM or FM, you could probably never look at an X-ray. A lot of orthopods have x-ray machines in the office, some ENTs have small CTs that can scan the head, a lot of docs in the ED will start treatment or decide dispo before the official read, radiation oncologists use images in treatment planning.

This is 100% incorrect. I think first off as a well-rounded doc you should know how to read some basic films no matter what field (CXR, CT head, etc). It's just part of a good medical education. As an IM doc, you need to know how to read radiology a LOT, especially in subspecialty. Off the top of my head

- definitely need to know how to read chest x-rays on any patient to look for pleural effusion, PNA, evaluate placement of chest tubes/NG tubes/central lines, evaluate for ARDS, etc. Also can help with diagnosing things like Ao dissection and other acute things where you may not want to wait too long before calling the surgeons.
- chest CT reading is an excellent skill, esp for pulm/CC - in fact a good chunk of the pulm/CC boards involves being able to interpret CT findings. There's a lot of good diagnostic stuff that will help you determine the degree of ARDS, the interstitial diseases, the extent of a pleural effusion, etc
- cardiologists do a TON of radiology and actually have boards to specialize in them, including echocardiography, cardiac MRI, stress echo, nuclear stress imaging, etc
- Rheum has to get good at reading joint XRs and sometimes MRIs

etc etc - point is you should know how to read the films for your patients in any field and that def includes IM. There's obviously some much more complex radiology studies which might require some help from a radiologist in reading, but the basic stuff you should DEFINITELY know, and then quite a bit more especially in subspecialty medicine.

 

[FSU2013]

Well, looks like I stepped on some people's toes. Sorry, no reason for butthurt.

But even still, people mentioned acute findings which will be seen in the ED and critical care stuff which will hopefully be read by the ICU attending. EM is its own beast and CC docs have done fellowships. I absolutely think its important for a doc to look at their films, but for outpatient stuff you often time won't even have access to the films and will only get a report. For floor work, stuff rarely is so acute is has to be read before the radiologist can read it. If it is, they should probably be in the unit. I've def seen IM attendings who read the findings on the rads report and never look at the film. I'm not saying its ideal, but people do it all the time. My point isn't to say that FM or IM docs can't do it, I was just saying that they could probably get by without ever looking at a film. Is it lazy and cutting corners? Yea. But can it be done? Yea.

Also, someone mentioned that you know the patient and the radiologist doesn't. That's actually a gripe I heard from a radiologist recently - people ordering studies giving one word indications. If you give the radiologist a little more info, you'll probably get a better read.

 

[Winged Scapula]

I absolutely think its important for a doc to look at their films, but for outpatient stuff you often time won't even have access to the films and will only get a report. For floor work, stuff rarely is so acute is has to be read before the radiologist can read it.

No one should be sending their patients to facilities without digital imaging and storage. Its easy to get access to radiology images from local facilities, even on an outpatient basis. You just have to ask.

I can look at on-line images from my office or home (before reports are dictated and transcribed) from all the hospitals I go to and all independent radiology facilities as well. There is no reason why any IM or FM physician cannot do the same unless they have not bothered to ask.

What you may have been trying to say is that there are physicians who DON'T look at their own images and wait until the report comes in to call a consult. All general surgeons have gotten the consult call for free air 24 hours after a chest x-ray or abdominal film because no one bothered to check the film themselves.

 

[mimelim]

Well, looks like I stepped on some people's toes. Sorry, no reason for butthurt.

But even still, people mentioned acute findings which will be seen in the ED and critical care stuff which will hopefully be read by the ICU attending. EM is its own beast and CC docs have done fellowships. I absolutely think its important for a doc to look at their films, but for outpatient stuff you often time won't even have access to the films and will only get a report. For floor work, stuff rarely is so acute is has to be read before the radiologist can read it. If it is, they should probably be in the unit. I've def seen IM attendings who read the findings on the rads report and never look at the film. I'm not saying its ideal, but people do it all the time. My point isn't to say that FM or IM docs can't do it, I was just saying that they could probably get by without ever looking at a film. Is it lazy and cutting corners? Yea. But can it be done? Yea.

Also, someone mentioned that you know the patient and the radiologist doesn't. That's actually a gripe I heard from a radiologist recently - people ordering studies giving one word indications. If you give the radiologist a little more info, you'll probably get a better read.

Do you read other people's posts or just spout?

You will be an inferior physician if you don't read your own films. Through the course of a standard physician career, your patients will suffer as a direct result. Either from acuity or lack of clinical focus. We always give a one line description of why we are getting our films, vascular labs, echos etc. The radiologists have access to the patient's full chart if they want more (which they never do). Nobody is complaining about the quality of the read. The issue is that radiologists have not been seeing the patient every day or understand the exact clinical situation. As I previously stated, radiologists are key. We always check their reports because they pick up on stuff that most of us would completely miss.

The point is that you should have a basic understanding of every test you are sending off for and what you are looking for. It is unforgivable to send for an EKG and either 1) not look at it or 2) have no idea what you are looking at until a cardiologist tells you. Xrays, CTs, ultrasounds etc are no different. You need to be able to check the positions of your lines, tubes etc at a bare minimum.

 

[donkeykong1]

Anyone have a good resource for learning to read the cardio relevant stuff from a cXR? My lecture ppt wasn't all that great.

 

[Doctor D]

Felsons Chest or for a free resource look at learningradiology.com

 

[FSU2013]

Do you read other people's posts or just spout?

You will be an inferior physician if you don't read your own films. Through the course of a standard physician career, your patients will suffer as a direct result. Either from acuity or lack of clinical focus. We always give a one line description of why we are getting our films, vascular labs, echos etc. The radiologists have access to the patient's full chart if they want more (which they never do). Nobody is complaining about the quality of the read. The issue is that radiologists have not been seeing the patient every day or understand the exact clinical situation. As I previously stated, radiologists are key. We always check their reports because they pick up on stuff that most of us would completely miss.

The point is that you should have a basic understanding of every test you are sending off for and what you are looking for. It is unforgivable to send for an EKG and either 1) not look at it or 2) have no idea what you are looking at until a cardiologist tells you. Xrays, CTs, ultrasounds etc are no different. You need to be able to check the positions of your lines, tubes etc at a bare minimum.

Are you kidding me? Did you even read my post or did you just spout? How did everyone read my post and think I said that only radiologist should ever read films? I said your average IM or FM doc could get away without reading films. I explicitly said that it's lazy and cutting corners. I didn't suggest it's ideal or it is how medicine is best practiced. I just said some people get away with it. I never said that is how I intend to practice.

All I was saying is that I've been in/had friends rotate in small outpatient clinics that only get the written rads report +/- a cd with images. I've also seem hospitalist who read the report and never open pacs. It happens. Are they the doctors I aspire to be like? No. Are they the best docs in the hospital? No. Do they exist? Yes.

Calm down everybody.

 

[JGimpel]

Knowing the basics of what a normal fundoscopy, heart and lung auscultation, as well as a CBC/CMP or normal imaging study, are the foundation of a great preparation for your licensing exams, USMLE or COMLEX, since that will be expected of you on them. To only study the most common abnormals, just enough to pass these exams will definitely put you at a disadvantage later on in your training. You can call for a stat read or "over-read" from the on-call radiologist or Nighthawk if you're on a night block, but do it enough times when you should have been able to see the basic "sick or not sick" and acted upon it with empiric treatment, and you will get less than glowing reviews from your preceptor and possibly be put on probation for a while. Good screening with a solid history, physical and incorporation of pertinent history will take you much further than shotgunning your labs, imaging and consults then not knowing what to do with them when the image comes back. Yup, just like your medical school professors keep telling you...

 

[ArcGurren]

Do you read other people's posts or just spout?

You will be an inferior physician if you don't read your own films. Through the course of a standard physician career, your patients will suffer as a direct result. Either from acuity or lack of clinical focus. We always give a one line description of why we are getting our films, vascular labs, echos etc. The radiologists have access to the patient's full chart if they want more (which they never do). Nobody is complaining about the quality of the read. The issue is that radiologists have not been seeing the patient every day or understand the exact clinical situation. As I previously stated, radiologists are key. We always check their reports because they pick up on stuff that most of us would completely miss.

The point is that you should have a basic understanding of every test you are sending off for and what you are looking for. It is unforgivable to send for an EKG and either 1) not look at it or 2) have no idea what you are looking at until a cardiologist tells you. Xrays, CTs, ultrasounds etc are no different. You need to be able to check the positions of your lines, tubes etc at a bare minimum.

Very much would agree with this. There are certain skills that should be common to every single specialty of medicine; I think we can agree that reading CXRs and EKGs are part of those skills.

Now, FSU, we get that physicians do cut corners, though I've never personally seen an outpatient practice which didn't have access to its own radiology (in fact typically patients are asked to take their CDs with them to their primary docs with the x-ray/CT/MRI on them). That is absolutely not the standard of practice. Most IM/FM physicians I've seen at the very least read their own chest x-rays and don't bother waiting for the official read. So nobody is "butthurt"; the way you phrased your earlier post suggested that somehow you can get away as a physician by not reading your own films. You can't. People do it, but it always comes back to bite them in the ass.

 

[Mattchiavelli]

It is field dependent,as a neurology resident I have to read CTs and MRIs of the brain and spinal cord. There are some basics I have to know like blood/mass and normal anatomy for a CT and normal anatomy, acute stroke for MRI and some more stuff.

The key is you will have to know more acute things for your specialty but not everything, for example I'm not looking at any plain films of long bones anymore, no KUBs, chest/pelvis CTs etc or at least not basing any decisions on them without an official radiologist interpretation. The same goes for less acute specialty things that are ambiguous and/or don't fit the clinical picture.

 

[sazerac]

Every FM doc I have worked with does their own imaging and reads. If the image is complicated or ambiguous they might zap the image to a radiologist, but for the most part it seems unnecessary. It basically follows the rest of FM philosophy- keep most of stuff in house where it is faster and cheaper for everybody, and seek specialized help when appropriate.

 

[SouthernSurgeon]

Every FM doc I have worked with does their own imaging and reads. If the image is complicated or ambiguous they might zap the image to a radiologist, but for the most part it seems unnecessary. It basically follows the rest of FM philosophy- keep most of stuff in house where it is faster and cheaper for everybody, and seek specialized help when appropriate.

It's very unlikely that FM docs are interpreting (i.e. billing) on their own. They may be looking at the films themselves and providing the initial feedback to patients, but the images are still going to a radiologist for final reads. They'd be exposing themselves to tremendous liability otherwise.

 

[Xerxes1729]

In the ED, I look at all my own CT images. A radiologist still reads everything, but I get a lot of calls from them telling me about a massive subdural after I've already started mannitol and neurosurgery if prepping for the OR. I rarely get plain film reads back in a useful time. On the other hand, I know basically nothing about MR, so on the rare occasions I order one I am at the mercy of radiology.

 

[SouthernSurgeon]

I rarely get plain film reads back in a useful time.

On one of my ICU months, I got a STAT page from the radiology staff for a read on a chest x-ray where the patient had an unexpected pneumothorax.

I called him back and was like...I know, we put a chest tube in the patient 12 hours ago...and there is another film in your queue after the chest tube placement confirming resolution...

 

[sazerac]

It's very unlikely that FM docs are interpreting (i.e. billing) on their own. They may be looking at the films themselves and providing the initial feedback to patients, but the images are still going to a radiologist for final reads. They'd be exposing themselves to tremendous liability otherwise.

I am pretty sure he did the reads himself. This was a standalone 2 doc clinic near a mountain biking area. Visitors came in all the time with arm and ankle injuries. He only went digital a few years ago, and I know that before digital he would snap a picture to verify the extent if the internal damage, and then cast, splint, or refer to an orthopedist as appropriate. He certainly didn't develop the films, and then drive them an hour across town to the nearest radiologist.

"Billing" may be a code word I don't understand yet, but I know he charged about $40 per X-ray taken.

Maybe he was exposing himself to tremendous liability, but people seemed pretty happy to have an MD nearby who could patch them up or tell them they were done biking on this vacation.

 

[ArcGurren]

I am pretty sure he did the reads himself. This was a standalone 2 doc clinic near a mountain biking area. Visitors came in all the time with arm and ankle injuries. He only went digital a few years ago, and I know that before digital he would snap a picture to verify the extent if the internal damage, and then cast, splint, or refer to an orthopedist as appropriate. He certainly didn't develop the films, and then drive them an hour across town to the nearest radiologist.

"Billing" may be a code word I don't understand yet, but I know he charged about $40 per X-ray taken.

Maybe he was exposing himself to tremendous liability, but people seemed pretty happy to have an MD nearby who could patch them up or tell them they were done biking on this vacation.

That sounds a lot more like an urgent care clinic than an FM clinic

 

[sazerac]

That sounds a lot more like an urgent care clinic than an FM clinic

Well I know cities have lots of labels and designations and stuff, but out at the point of service it is just FM board certified MDs providing short term health care to the visitors and long term health care to folks who live nearby, because hospitals can be a long ways away. Call it what you want, but FM's are definitely taking X-rays and reading them and sending patients or insurance the bill when it meets the needs of the community.

 

[cowme]

Also, someone mentioned that you know the patient and the radiologist doesn't. That's actually a gripe I heard from a radiologist recently - people ordering studies giving one word indications. If you give the radiologist a little more info, you'll probably get a better read.

Amen.

We (radiologists) only have so much time allotted to read a film. Just like you guys don't do full neuro exams on every patient, we don't trace out every anatomical structure of every CT. If the only clinical history we get is "pain," then all we can do is give a general overview of each structure.

Now if you said: "punched in left flank, rule out vascular injury to kidney," well then we could focus thoroughly on the area in question and give you a better report.

 

[FSU2013]

Amen.

We (radiologists) only have so much time allotted to read a film. Just like you guys don't do full neuro exams on every patient, we don't trace out every anatomical structure of every CT. If the only clinical history we get is "pain," then all we can do is give a general overview of each structure.

Now if you said: "punched in left flank, rule out vascular injury to kidney," well then we could focus thoroughly on the area in question and give you a better report.

Finally, someone on this thread who doesn't hate me, lol.

 

[Winged Scapula]

Amen.

We (radiologists) only have so much time allotted to read a film. Just like you guys don't do full neuro exams on every patient, we don't trace out every anatomical structure of every CT. If the only clinical history we get is "pain," then all we can do is give a general overview of each structure.

Now if you said: "punched in left flank, rule out vascular injury to kidney," well then we could focus thoroughly on the area in question and give you a better report.

I agree that would be helpful IF our EMR allowed us that much space to write things in. I can barely get in pre-op eval; cough.

 

[cowme]

Agreed. The EMR systems are freaking jokes because they are never linked in with pacs. As an intern, I would give excellent histories for every study i ordered from the ER. I went to the reading room one day, and saw that rather than getting my elaborate history, the pacs indication read: "needs MRI brain"

 

[ArcGurren]

Finally, someone on this thread who doesn't hate me, lol.

Oh cry me a freaking river. Nobody hates you or is persecuting you. Every point we made still stands.

In general most of the radiology requests we've seen have given sufficient indication. For example, an order for a CXR obtained after a line would always read "s/p line placement" (that's about the shortest order justification I've seen) - I'd say that's enough for a radiologist to know that they're supposed to verify placement of the line and look for a pneumothorax.

 

[FSU2013]

Oh cry me a freaking river.

Chill out dude, it was a joke.

 

[KnuxNole]

Thank goodness for radiology rounds in medicine, otherwise it'd be tough to learn how to read films.

Unless we can sneak into the reading room and get extra rads electives 😛