Reading CTs: essential skill?

[TheComebacKid]

I feel pretty good with reading the basics of a head CT on my own. I could confidently identify a dissection flap, or a large saddle PE, pneumonia/hemothorax, mass etc. Honestly, so could a medical student.

But once I get into the abdomen, it's just a bunch of mush. I can make out the major organs but I just don't feel that confident in making a diagnosis. Fat stranding? What?

Unlike X-rays, which I feel like is a requirement to interpret and read on our own, how often (if ever) are we expected to read CTs? The community site I rotate at has 24/7 radiology reads on CTs, however overnight the ED docs read plain films.

I have some residency elective time coming up and wondering how much of this I should focus on radiology, specifically reading CTs.

I continue to try to look at all abdominal CTs and correlate the images with the radiologist interpretation, but most of the time I don't know what the hell they are looking at.

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[Janders]

I find it very very helpful, personally, to be comfortable with Torso CT.

At our community shop, CT reading is outsourced (like most places) off-hours. Sometimes the reads can be 1-2 hours. Thats a long time. As well, I've caught MANY missed things... divertic, abscesses, appy, fracture after fracture. We, of course, have the benefit of knowing where the patient hurts... A bit easier to find that scapular fracture when you look for it.

Anyway, it isn't mandatory but I personally look at every CT I order... and I am NOT an anal-retentive type in practice. I was lucky to have an incredible IM/Radiology dual boarded instructor in med school (she was incredible!), and some very pleasant emergency-radiologists working just down the hall in residency (they also participated in weekly conference). I absorbed a lot from them.

 

[Groove]

1) Try to interpret the CT 2) Read the formal report 3) Go back and try to identify what you missed

Rinse, repeat. It's really that simple. That's literally all I did in residency. When I had a question, I'd pop my head in the radiology reading room and ask one of the attendings or residents. After seeing so many scans and pathology you start to develop pattern recognition and you'll start recognizing things immediately that might have taken time before. After all, this is basically how radiology residents learn. They go through enormous amounts of scans and pathology.

Fundamentals of Body CT is a good read for additional information if you're interested. I have a copy and it's a great reference.

 

[thegenius]

I have some residency elective time coming up and wondering how much of this I should focus on radiology, specifically reading CTs.

Not a necessity to be a good, board certified emergency medicine physician. There is a reason why radiology requires 4 years of training. If you want to do a radiology elective because you find it interesting, then that's OK!

As you said, there are radiologists on call 24/7 to read CT's, MRI's, Nuc Med studies everywhere because they are hard to read. I'm not sure why they also don't read xrays, probably a cost issue (at the end of the day, all xrays get formal radiology read at my site, just like everywhere else. But maybe not immediately like CT, MRI, NM).


I'm pretty good at reading CT's of all sorts, I used to in my spare time in med school and residency pull up CT's of all sorts and read them, then compare my read to the Radiologist. You end up getting really good when you can pick up non-emergent findings (atrophy out of proportion to age on Head CT, adrenal adenomas, bowel wall thickening, lymphadenopathy on Chest/Abd/Pelvis, etc.)

 

[thegenius]

1) Try to interpret the CT 2) Read the formal report 3) Go back and try to identify what you missed

Rinse, repeat. It's really that simple. That's literally all I did in residency. When I had a question, I'd pop my head in the radiology reading room and ask one of the attendings or residents. After seeing so many scans and pathology you start to develop pattern recognition and you'll start recognizing things immediately that might have taken time before. After all, this is basically how radiology residents learn. They go through enormous amounts of scans and pathology.

Fundamentals of Body CT is a good read for additional information if you're interested. I have a copy and it's a great reference.

There is a really good app (free too) on the iPhone, I can't remember what its called, but it allows you to scroll through like 50+ CT's and do your own reads, then compare it to the read by a radiologist. It was written by a radiologist too.

 

[Tenk]

I can diagnose most things on ct, ultrasound and X-ray now and am rarely wrong versus the final report. MRI I am getting better with but I order so few it’s harder. The best method is to look at all your studies. Every single one. One of my favorite attendings taught me that and it most certainly works.

 

[gamerEMdoc]

Its just not the delay in CT, there's also tons of missed stuff. We have the hindsight of knowing why we ordered the scan and exactly what we are looking for. I've picked up missed SDH's in the head, missed appys, you name it. You should ALWAYs look over your own films. Radiologists aren't 100% accurate any more than we are 100% accurate at what we do. Another set of eyes is always helpful, especially one that saw the patient.

 

[DrDrummer]

There is a really good app (free too) on the iPhone, I can't remember what its called, but it allows you to scroll through like 50+ CT's and do your own reads, then compare it to the read by a radiologist. It was written by a radiologist too.

A Night in the ED

There is a great app for iOS that accompanies this called Radiology 2.0 One Night in the ED. Fantastic teaching tool, this guy is a champion for distributing this for free.

 

[thegenius]

A Night in the ED

There is a great app for iOS that accompanies this called Radiology 2.0 One Night in the ED. Fantastic teaching tool, this guy is a champion for distributing this for free.

That's it! It's a fabulous app, very well done, can scroll through full CT's without annotation, and then with annotation. It's free, recommend to all!

 

[southerndoc]

Its just not the delay in CT, there's also tons of missed stuff. We have the hindsight of knowing why we ordered the scan and exactly what we are looking for. I've picked up missed SDH's in the head, missed appys, you name it. You should ALWAYs look over your own films. Radiologists aren't 100% accurate any more than we are 100% accurate at what we do. Another set of eyes is always helpful, especially one that saw the patient.

Some state medical boards view the ordering physician as responsible for an image or lab's interpretation regardless of their training. As gamerEMdoc points out, you should always look at your own studies (especially negative ones) because there are rare but life-threatening diagnoses that occasionally get missed. SDH, pneumothorax, etc. The 30 seconds you take to look at your own film may save you months of headache from litigation.

 

[southerndoc]

Off topic, but what is this verified expert under my name now? :O

 

[Groove]

Aww man, I wanna be a verified expert. My mom thinks I'm an expert, does that count?

 

[Apollyon]

Off topic, but what is this verified expert under my name now? :O

What?? You didn't ask for it? I had to grovel myself into submission!

(Not really - just asked)

 

[thegenius]

Some state medical boards view the ordering physician as responsible for an image or lab's interpretation regardless of their training. As gamerEMdoc points out, you should always look at your own studies (especially negative ones) because there are rare but life-threatening diagnoses that occasionally get missed. SDH, pneumothorax, etc. The 30 seconds you take to look at your own film may save you months of headache from litigation.

Do you know which states are these?

 

[Vandalia]

Do you know which states are these?

I am not aware of any. Heck, I cannot recall my state medical board acting on a "competence"/"practice" issue in well over a year. Probably several years.

You can be held responsible for ensuring that reports have in fact been written and are responsible for actually reading those reports, but not the actual imaging. You can also be held responsible for the treatment of a patient in a malpractice case if imaging is not a "gold standard". But that is not a board issue, that is a malpractice issue. For example, if there is exceptionally strong clinical indication of appendicitis, and you rely on a non-specific CT report to completely exclude the diagnosis, you will be in trouble. But I am willing to bet there is no state board out there that has ever taken disciplinary action against an internal med physician for not reading an MRCP at the same level as a radiologist.

However, a board would act if your choice of imaging was so poor as to constitute a "threat to public safety."

 

[southerndoc]

thegenius, you will likely not find any set rule on this. Most boards view it based on peer review after successful litigation or board complaints. Almost all are for gross violations -- obvious saddle PE that radiology read as negative and the patient was discharged home. Patient dies, family sues, medical board is notified due to successful litigation, it's sent to a peer reviewer, peer reviewer determines physician ordering exam should have viewed the exam and noted the abnormality.

 

[gamerEMdoc]

Off topic, but what is this verified expert under my name now? :O

Someday. Someday I hope to achieve this level of prestige.

 

[BoardingDoc]

Someday. Someday I hope to achieve this level of prestige.

SDN is developing some serious merit badge creep.

 

[deleted103644]

Its just not the delay in CT, there's also tons of missed stuff. We have the hindsight of knowing why we ordered the scan and exactly what we are looking for. I've picked up missed SDH's in the head, missed appys, you name it. You should ALWAYs look over your own films. Radiologists aren't 100% accurate any more than we are 100% accurate at what we do. Another set of eyes is always helpful, especially one that saw the patient.

You should also include more information when ordering the study than “emergent” or “pain”.

 

[Lawpy]

Someday. Someday I hope to achieve this level of prestige.

You can probably get one

 

[gamerEMdoc]

You should also include more information when ordering the study than “emergent” or “pain”.

I do, and its a lot better with CPOE, since I control what the order says. Still, even despite that, there is still a big advantage of having seen the patient.

 

[Psai]

SDN is developing some serious merit badge creep.

Yeah i nearly donated a bunch of money to get some badges and keep up with the Joneses

 

[deleted109597]

Off topic, but what is this verified expert under my name now? :O

In an effort to be more transparent to users, and so they can put more weight on advice, people that are known to be attendings/well versed in the field get expert badges. You can certainly ask for them, but many longterm users are getting them without asking.
It's so new users aren't taking med student advice with the same weight as attending advice.

 

[Lawpy]

In an effort to be more transparent to users, and so they can put more weight on advice, people that are known to be attendings/well versed in the field get expert badges. You can certainly ask for them, but many longterm users are getting them without asking.
It's so new users aren't taking med student advice with the same weight as attending advice.

😕 how do expert banners differ from verified physician banners?

and how do expert banners differ from SDN advisor banners?

 

[GeneralVeers]

😕 how do expert banners differ from verified physician banners?

and how do expert banners differ from SDN advisor banners?

I'll file them away with my stack of expired ACLS, PALS, and NIHSS merit badges.

 

[RustedFox]

I need a banner. I'm a hot sauce expert. I will challenge any poster on here with regard to the science of saucy Scoville units.

 

[Groove]

I need a banner. I'm a hot sauce expert. I will challenge any poster on here with regard to the science of saucy Scoville units.

I have periodic "hot challenges" at work and have completed five so far.

Hot Challenge #1:

Hot Challenge #2

Hot challenge #3

Hot Challenge #4 (1.5 million SCU)

\

Hot Challenge #5 (9 million SCU)

At which point the contestants started to suffer... My scribe threw up in the bathroom on that last challenge and my colleague got so diaphoretic he was dripping sweat and I was afraid he was having an MI or had perforated a gastric ulcer. I'm normally pretty stoic with these things but the chocolate had me hugging the toilet bowl for about 5 mins though I never actually puked. (Also had piercing epigastric pain for about 3 days..) I think if I go any further, I'll get sued. I was actually going to put the gumballs in a bowl in the doctor's lounge but then thought better of it as we've got several older surgeons that would have likely coded after eating them and I would have had to deal with them in the ER. So... I've put the work hot challenges on hold... Much to everyone's relief! lol...Have fun with those.

 

[RustedFox]

I think the hottest thing that I've ever eaten was a chicken stir-fry of my own design.
I was in medical school (Saint George's) and a roommate gave me a bunch of peppers that he picked up from a street vendor downtown without thinking about it (he didn't eat spicy food at all). Not knowing what they were (Scotch Bonnets), I just cut 'em up and tossed 'em in. BIG MISTAKE.

 

[deleted109597]

I need a banner. I'm a hot sauce expert. I will challenge any poster on here with regard to the science of saucy Scoville units.

I'll own you. Next time I'm in Ybor, you're on, foxy

 

[deleted109597]

😕 how do expert banners differ from verified physician banners?
and how do expert banners differ from SDN advisor banners?

We aren't ignoring this question. There's actually a fair amount of discourse going on about what each specific banner means. Likely, there will be a post explaining all of it, and I expect to cross-link/quote it here.
In the meantime, they're all expired merit badges that @GeneralVeers once had.

 

[thegenius]

At which point the contestants started to suffer... My scribe threw up in the bathroom on that last challenge and my colleague got so diaphoretic he was dripping sweat and I was afraid he was having an MI or had perforated a gastric ulcer. I'm normally pretty stoic with these things but the chocolate had me hugging the toilet bowl for about 5 mins though I never actually puked. (Also had piercing epigastric pain for about 3 days..)

umm sounds like fun

I think if I go any further, I'll get sued. I was actually going to put the gumballs in a bowl in the doctor's lounge but then thought better of it as we've got several older surgeons that would have likely coded after eating them and I would have had to deal with them in the ER. So... I've put the work hot challenges on hold... Much to everyone's relief! lol...Have fun with those.

That would be something else! The hospital would have gotten sued I bet, after you coded the CT surgeon for 45 minutes. Autopsy report: perforated gastric and numerous small bowel viscouses after a food-stuff eroded through the stomach, all the bowel and into the scrotum.

 

[RustedFox]

I'll own you. Next time I'm in Ybor, you're on, foxy

 

[dchristismi]

Now I enjoy a little heat, but prefer to retain the taste of whatever I'm enjoying... so I will volunteer to officiate this challenge. I'll see you both in Ybor.

Also, to go back to the original intent, if I can visualize the appendix, the probability of appendicitis is 100%.

 

[meister]

You guys talking about radiology TATs of 2 hours and no reads on X-rays overnight makes me think I picked the wrong job!

 

[bravotwozero]

I have periodic "hot challenges" at work and have completed five so far.

Hot Challenge #1:

Hot Challenge #2

Hot challenge #3

Hot Challenge #4 (1.5 million SCU)

\

Hot Challenge #5 (9 million SCU)

At which point the contestants started to suffer... My scribe threw up in the bathroom on that last challenge and my colleague got so diaphoretic he was dripping sweat and I was afraid he was having an MI or had perforated a gastric ulcer. I'm normally pretty stoic with these things but the chocolate had me hugging the toilet bowl for about 5 mins though I never actually puked. (Also had piercing epigastric pain for about 3 days..) I think if I go any further, I'll get sued. I was actually going to put the gumballs in a bowl in the doctor's lounge but then thought better of it as we've got several older surgeons that would have likely coded after eating them and I would have had to deal with them in the ER. So... I've put the work hot challenges on hold... Much to everyone's relief! lol...Have fun with those.

I think the hottest thing that I've ever eaten was a chicken stir-fry of my own design.
I was in medical school (Saint George's) and a roommate gave me a bunch of peppers that he picked up from a street vendor downtown without thinking about it (he didn't eat spicy food at all). Not knowing what they were (Scotch Bonnets), I just cut 'em up and tossed 'em in. BIG MISTAKE.

I'll own you. Next time I'm in Ybor, you're on, foxy

you guys are a bunch of masochists...

 

[Old_Mil]

I feel pretty good with reading the basics of a head CT on my own. I could confidently identify a dissection flap, or a large saddle PE, pneumonia/hemothorax, mass etc. Honestly, so could a medical student.

But once I get into the abdomen, it's just a bunch of mush. I can make out the major organs but I just don't feel that confident in making a diagnosis. Fat stranding? What?

Unlike X-rays, which I feel like is a requirement to interpret and read on our own, how often (if ever) are we expected to read CTs? The community site I rotate at has 24/7 radiology reads on CTs, however overnight the ED docs read plain films.

I have some residency elective time coming up and wondering how much of this I should focus on radiology, specifically reading CTs.

I continue to try to look at all abdominal CTs and correlate the images with the radiologist interpretation, but most of the time I don't know what the hell they are looking at.

From a medicolegal aspect you aren't going to be dispoing patients based on your CT read. So meh. Save the brain space for something more relevant.

 

[deleted109597]

From a medicolegal aspect you aren't going to be dispoing patients based on your CT read. So meh. Save the brain space for something more relevant.

I frequently do. Sometimes the teleradiologist takes an hour to read it. If I see free air, or ICH, or any number of things I can identify, I can have them going away within 20 minutes.
I'm not taking about exact measurements of kidney stones, and I don't discharge anybody that I'm reading their CT as negative, only positive findings.

 

[gamerEMdoc]

I frequently do. Sometimes the teleradiologist takes an hour to read it. If I see free air, or ICH, or any number of things I can identify, I can have them going away within 20 minutes.
I'm not taking about exact measurements of kidney stones, and I don't discharge anybody that I'm reading their CT as negative, only positive findings.

True. Waiting for a formal read when there is delays for reads can be a legal risk itself. If someone has AMS and you order a head CT and it takes 2 hrs to get a read that comes back and says epidural hematoma, and you never looked at the CT, that could be a problem.

 

[SamtheWise]

True. Waiting for a formal read when there is delays for reads can be a legal risk itself. If someone has AMS and you order a head CT and it takes 2 hrs to get a read that comes back and says epidural hematoma, and you never looked at the CT, that could be a problem.

So what is the standard we're held to? Are we expected not to miss things that most other reasonable Emergency Physicians would not miss? Like a huge head bleed, a big ascending aortic dissection, but missing like a small pneumothorax or clinically insignificant traumatic SAH would be reasonable?

 

[gamerEMdoc]

The standard of care is what a reasonable ED doc would do. We aren't radiologists, but we aren't Opthalmologists, CT surgeons, Pediatricians, etc. Yet in our field we have to do a little of everything. And part of that is looking at our own films. No one would expect an ED doc to pick up some subtle finding, but a massive epidural hematoma is another thing. I think it would be defensible to an extent to say you looked at a film, didn't see something, and were awaiting radiologies reading for 99% of stuff, since most things aren't that time urgent. But I don't know that its defensible to say you just didn't look at the films.

Besides, it's just good medicine to have a second set of eyes on stuff. I had a radiologist miss an appy the other day. I've had them miss subdurals. I had them miss free air in the abdomen from a perf once. They are no more perfect at their job than we are at our job. A second set of eyes on a film is always helpful.

 

[tkim]

SDN is developing some serious merit badge creep.

 

[Apollyon]

😕 how do expert banners differ from verified physician banners?

and how do expert banners differ from SDN advisor banners?

And what IS an "SDN Ambassador"?

 

[deleted109597]

And what IS an "SDN Ambassador"?

This is a new volunteer level for members that have demonstrated significant contributions to the student community here at SDN. Ambassadors work to increase the quality of site content and provide editorial oversight. They ensure the content of their forums are up-to-date and help to ensure we are meeting our members' needs.

https://forums.studentdoctor.net/threads/welcome-lawper.1360675/#post-20597891

 

[RadsGuy]

1) Try to interpret the CT 2) Read the formal report 3) Go back and try to identify what you missed

Rinse, repeat. It's really that simple. That's literally all I did in residency. When I had a question, I'd pop my head in the radiology reading room and ask one of the attendings or residents. After seeing so many scans and pathology you start to develop pattern recognition and you'll start recognizing things immediately that might have taken time before. After all, this is basically how radiology residents learn. They go through enormous amounts of scans and pathology.

Fundamentals of Body CT is a good read for additional information if you're interested. I have a copy and it's a great reference.

That's a good book.

I'd like to caution you about looking at it yourself, then reading the report. What I see as a radiologist is not what I put in the report. And if you come back and talk to me, I may come down harder on or against some things that I just can't put in writing. I blow off a lot of things, downplay some, don't mention others and word play quite a bit depending on what I think should be done for the patient. For example, "disc material is abutting the exiting nerve root" or "disc material is impinging on the left S1 nerve root. Correlate with a left S1 radiculopathy". Using hyperbolic words like "obliterating" the perineural fat instead of using the word "encroaching". Words like "almost certainly benign" or "cancer until proven otherwise". And of course, I miss things too. Miss stuff every day. Every radiologist does. So just because it's not in the report, doesn't mean what you're seeing isn't real.

 

[RadsGuy]

Can't hurt for you to learn how to look at basic belly CTs but let me ask you, if it's obvious to you, do you think it'll be obvious to the radiologist? Not saying we don't miss things. We do every day. And I'm talking about CT or MRI. X-ray, you will always be better than a radiologist who has the history of "Trauma pain" rather than "base of 5th metatarsal hurts when I push on it." But the answer is at least...Probably, right?

I'm a big believer in putting your time into things that will get you the most benefit. Learning curve is steep and after so many hours, at best you'll be a below average radiologist. Why not put those hours into becoming a very above average ER doc? I think your time is better spent learning what to order and why rather than how to read. Most ER docs I know still call me all the time saying stuff like "so there's a guy in here who's had HCC and IR has done TACE procedures x 3 on him and his last one was 2 weeks ago, and now his belly hurts. what should I order?" I think your time is better spent learning what to order instead of learning how to tell the difference between treated tumor, liver abscess, and biliary necrosis.

If you have the time devote to becoming an above average ER doc and a below average radiologist, then definitely go for it. But nobody has that much time and the more you learn, the more you start to forget. Just an opinion.

 

[VA Hopeful Dr]

Can't hurt for you to learn how to look at basic belly CTs but let me ask you, if it's obvious to you, do you think it'll be obvious to the radiologist? Not saying we don't miss things. We do every day. And I'm talking about CT or MRI. X-ray, you will always be better than a radiologist who has the history of "Trauma pain" rather than "base of 5th metatarsal hurts when I push on it." But the answer is at least...Probably, right?

I'm a big believer in putting your time into things that will get you the most benefit. Learning curve is steep and after so many hours, at best you'll be a below average radiologist. Why not put those hours into becoming a very above average ER doc? I think your time is better spent learning what to order and why rather than how to read. Most ER docs I know still call me all the time saying stuff like "so there's a guy in here who's had HCC and IR has done TACE procedures x 3 on him and his last one was 2 weeks ago, and now his belly hurts. what should I order?" I think your time is better spent learning what to order instead of learning how to tell the difference between treated tumor, liver abscess, and biliary necrosis.

If you have the time devote to becoming an above average ER doc and a below average radiologist, then definitely go for it. But nobody has that much time and the more you learn, the more you start to forget. Just an opinion.

Just to devil's advocate slightly, there are places where you don't have in-house 24/7 coverage. In residency our radiologists stopped working at 7pm (contract tele-radiology between then and 6am). We learned quickly to take the overnight reads with a grain of salt as I'd say a solid 10-20% got changed the next morning when our radiologists did the final official read.

 

[RadsGuy]

Just to devil's advocate slightly, there are places where you don't have in-house 24/7 coverage. In residency our radiologists stopped working at 7pm (contract tele-radiology between then and 6am). We learned quickly to take the overnight reads with a grain of salt as I'd say a solid 10-20% got changed the next morning when our radiologists did the final official read.

Valid point. I think the real advantage of you knowing how to look at scans is that sometimes when the rads get behind, it helps when you look at the studies and let us know that something is really wrong (massive bleed) and needs to read sooner rather than later. I have personally, unfortunately, sat on perforations and bleeds for over an hour because the volume is too much to keep up so it helps to have you looking as things come off. The CT and MRI techs help us out too with this because they can see the images as they come off and they usually call and say, "hey the images are only have done but you may want to take a look at this, it looks messed up".

As an aside, there's been a pretty massive shift in the last 5 years though for rads with regard to tele. They used to be general radiologists who read everything and are obviously not as good as your neurorads or MSK rads in house. But, hospitals are demanding 24/7 subspecialized coverage now and most groups have had to evolve. Fewer and fewer jobs are advertised as general radiology positions and many overnight telerad jobs are strictly for people who have neuroradiology training. There are still many out of date general rads out there throwing out dangerous reads, but it's much less than it used to be.

 

[deleted109597]

I'm going to say that of course we would be a below average radiologist. Just like we will be a below average orthopod. Or a below average cardiologist.
There are some things I'm never going to be able to do. Not being able to critically look at the images I order and making decisions based on them isn't one of them. It's akin to saying I should never splint or reduce a fracture, or ever perform a bedside ultrasound.
Nobody is saying you aren't better at reading them, and certainly I don't look for the things you do. I'm just looking for the pathology I'm considering, not all pathologies ever.

 

[meister]

When you guys find stuff we miss please just give us a call rather than immediately refer to departmental QA or whatever. TIA.

 

[RadsGuy]

I'm going to say that of course we would be a below average radiologist. Just like we will be a below average orthopod. Or a below average cardiologist.
There are some things I'm never going to be able to do. Not being able to critically look at the images I order and making decisions based on them isn't one of them. It's akin to saying I should never splint or reduce a fracture, or ever perform a bedside ultrasound.
Nobody is saying you aren't better at reading them, and certainly I don't look for the things you do. I'm just looking for the pathology I'm considering, not all pathologies ever.

I think we're pretty much on the same page, but are you saying that you critically look at a CT that you order and make decisions based on your read alone? Bc if you do, then yea you should learn how to read imaging (this may be true if you're in a rural area). If you always wait for the final read before discharging or calling up to admit though, then I still feel like the hours your put in studying are better used on other things since your management is independent of your read. Right? I would put most people in that category.

POC ultrasound is different than what I do and not a great analogy. FAST exams are def not my thing either. For example, if the patient's labs are fine and their history and exam is not concerning and you don't see anything grossly wrong on your POC ultrasound, then that's a good thing and 99% chance they wouldn't benefit from a formal ultrasound. I don't think you should stop doing those. That stuff helps improve efficiency and triage. I'm saying that I think if you see something in the GB that's not normal, you don't just treat. You order a formal US. Right?

In small town Alabama, you're probably going to reduce and cast. In NYC, you may call ortho resident to come reduce and cast. In between sized ER dept, you may just reduce and splint. But either way they follow up with ortho who either re-reduces if you've done a crappy job, casts if you've done a good job and it's non-operative, or even re-casts if there's been a big time interval and the swelling has gone down so they can get a better cast than when the patient saw you, or book the patient for surgery. In a couple of those scenarios, you doing a good reduction and splint helps. So I think you should continue to reduce and splint.

What I'm trying to say is that your management doesn't change based on how well you can interpret images (POC ultrasound excluded), so why spend all that time trying when you could get better at something else? I don't re-interpret pathology slides from my biopsies or go talk to ER patients to check your h/p's. I just trust that my colleagues are better at it than me and think that my time is better spent getting smarter at what I do instead of what my colleagues do. And I don't buy the 2 examples you gave because of above and I think they're only loosely related to what we're talking about.