The Value of Radiologists

[Fundamentals]

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Hey everyone, long time lurker and first time poster. I am posting this thread in this subforum because I want to hear what the referring clinicians/surgeons have to say, what you as residents and attendings outside of this field actually feel.

I'm in my final stretch of medical school and have applied to/been excited about a career in radiology. I loved the diagnostic aspects, the fact that you get to cover such a wide range of pathology, the puzzle solving etc....However, recent experiences have made me feel absolutely crushed about the prospects of this field.

One thing I truly loved about this field was the fact that they were helping making diagnoses for referring physicians. Truly being a consultant that offered value to others. Some of my favourite experiences in radiology were when surgeons or clinicians would come to the reading room to go over a case that was troubling them. I'd get incredibly excited about that interaction, and loved how it felt like radiologists were helping so many intelligent physicians with their work.

However, recent experiences have completely put a 180 on this perspective. On a current elective, the attendings were sitting together and talking about how the field was in huge trouble because so many surgeons are extremely proficient at reading the image and don't even need the radiologist. Especially with MSK or neuroradiologists, is it entirely just a legal matter why an orthopod can't bill for the knee mri or neurosurgeon can't bill for the head CT/MRI? It's been a while since the advent of PACS, and radiologists tell me that the amount of times a physician wants to discuss a case has gone down dramatically. My friends often laugh at my interest in this field, telling me that their attendings consistently complain about how useless a radiologist may be and that they can just read the image themselves. I am told regularly that surgeons (optho, ent, neuro, cardiac etc) can identify their pathology themselves, ER docs often make the patient disposition before receiving the radiology report, and internists often skim the report just to say 'its useless'. I find myself defending this field every single f**king day as others ask me why we even need radiologists....to the point now that i'm beginning to question myself!

I want to be of value in my career, first and foremost. I know not every report will be useful, but I want my referring clinicians to atleast respect and find utility in my opinion. I definitely do not want to be arguing my whole life about how i'm actually useful as a radiologist. I'm worried that I will feel like: "whats the point of working so hard on this CT/MRI when my opinion won't matter to the ordering physician"

So my question to all of you non-radiologists are, do you value the radiologist? Please be as honest as you can, even if it means bashing the field to the ground. I want to know what i'm getting into and how I can be somebody that actually makes a difference to my referring clinicians. Thank you for your time.

 

[shoal]

Brand new ED attending. I can read most XR. CT scans I can pick up obvious findings (large PE, ICH,traumatic abdominal injuries, and most appys). US training is good, and don't need rads on most stuff. But I still almost always rely on rads for final dx. I call if I see something and disagree. Radiology is always very helpful for me, and I appreciate their input and calls.

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[gutonc]

I value an interpretation. Don't just give me a laundry list of your findings (I can do that), tell me what you think they mean. That's the value of a well-trained radiologist.

 

[DrBowtie]

See if you can attend some tumor boards. You'll see both collaboration and respect towards Radiology.

As said above, you aren't there for the obvious. The janitor can spot the huge bleed with midline shift.

The ortho is very good at reading joints because they get operative feedback to correlate with the imaging. The great radiologists will follow up cases as well.

In general clinicians overestimate their ability to interpret studies, particularly the WHOLE study.

 

[Carlin]

I'm a radiation oncology resident. We very routinely consult our radiologists for assistance. Our neuroradiologists in particular are invaluable when we are treatment planning a difficult head and neck or CNS case. Our chair of neuroradiology announced that he will be retiring at the end of 2016 and everyone is already talking about what a loss that is for our hospital.

And it's not that we don't feel pretty capable of reading our own images. I spend a lot of time every day looking at CTs and MRIs. Even so, our well-trained radiologists are a huge resource that we use regularly.

I don't think I would worry about radiology becoming obsolete.

 

[j4pac]

No specialty covers the ass of all other specialties like Rads. They're great.

 

[J ROD]

Rads are important in the fact they assist other docs. Of course, every doc wants to say they are good and do not need assistance. And most of the surgeons and EM folks I have met are pretty sure of themselves.

Since they do not really have their own patients, they have to depend on other specialties for business. Hence, the somewhat disrespect.

Personally, I always valued their opinion. With that said, there are some that are better than others.

 

[da8s0859q]

I posted this in a thread in the radiology forum, but the short version is that, as an EM guy nearing the end of residency, I still read all of my imaging. I have called many times to discuss imaging based on the report. Only rarely have I caught things that were not seen by the radiologist. I love our radiologists and often await final reads which shape (or confirm) disposition, as is the style of many of our current attendings.

People who consider radiologists to be "useless" are underestimating the abilities and training of radiologists. Neither surgeons nor EM docs can consistently read advanced imaging to the level of a radiologist, radiologists and surgeons can't manage multiple significantly and/or critically ill patients simultaneously as EM docs can, nobody else can berate others and throw things as surgeons can, etc.

(Just kidding, surgeons.)

My two cents.

 

[meister]

Medicine is a field chock-full of insecure and overworked people. That results in some taking every opportunity to put you down just to elevate themselves, and it's quite sad if it's your friends doing this. Do not give much thought to statements about ortho or neurosurgery or whoever not needing radiologists, that belies a true misunderstanding of the way the system works. How would they ever get patients initially if not for us telling the PCP/EM/PA what the actual problem is? How would they sleep at night if they were asked to interpret and consult on every knee pain or headache in the ED? It makes no sense.

If you care so much about prestige then go into something else honestly, because radiology is largely a thankless specialty. You have to be ok with that. That being said, the idea of no one needing radiologists is quite comical. Subspecialty guys at academic centers can proficiently read the five pathologies they operate on, but point out something else going on in the image and they will gladly ignore it or plead ignorance. The attitude of "I don't need anyone else I am literally William Osler incarnate" is largely confined to academic centers and private practice can be quite different. The fact of the matter is, we are actually their best referrers! We tell the ED guy that there is no surgical problem in their 3AM belly pain narc seeker so he doesn't get yelled at by a grumpy surgeon. We refer surgeons all their cases indirectly by being the initial specialist to identify pathology. Once you understand the way modern medicine works, you realize how critical that is to the hospital functioning properly. It also makes some people's belligerence somewhat puzzling.

I have a feeling if the EMR recorded whenever someone loaded a report and displayed that information readily people might sing a slightly different tune!

 

[meister]

Also...you do develop great relationships with the ED and with surgeons and oncologists at tumor boards, though that is somewhat variable and institution dependent.

 

[KnuxNole]

I would say very valuable. If I depended on myself, or a non-radiologist as the only person looking at a CT scan, lots of bodybags will be made! I know that I wouldn't make a rash clinical decision unless I see what the radiologist says too...

I never understood when some people said they never bothered reading the interpretation. it's like "You aren't going to trust the experts?". Those were also the docs that got burnt and made a poor choice in management...

 

[mvenus929]

I look through all the images on my patients outside of ultrasounds (beyond head ultrasounds; I'm relatively good at those). US still doesn't make a lot of conceptual sense to me, and I can rarely see anything meaningful on it. I can spot the big stuff--the stuff that is going to make a huge difference in the patient's care (free air, a consolidated pneumonia, most pneumatosis intestinalis, significant fractures, head bleeds, hydrocephalus, etc). Chest x-rays and KUBs I feel like I can read on my own most of the time, but that's only a fraction of the imaging I order. I often can't see the subtle things--the non-displaced fracture, sometimes pneumothorax, questionable pneumatosis. Not to mention US for appendicitis or biliary atresia, or pyloric stenosis or the dozen of other things that I use it to look for.

Overnight, any images we order have to be sent elsewhere to be read, so you get decent at reading things quickly for the bad things. But it's not uncommon that we miss things on imaging that is picked up the next morning. We consult radiology all the time in our cancer kids, not only for the tumors themselves, but also for other imaging that would affect management (especially pan scans for fungus). I miss things on CT all the time just because there are so many structures and I'm looking for big things.

 

[RadOncDoc21]

No doubt, radiologists are very important in almost every aspect of medicine. Their final say is the equivalent to having life insurance.

As others above have stated, it's easy to catch the obvious but it never hurts to have an experienced well-trained eye.

 

[Fundamentals]

Thank you guys so much for your input, means a lot to hear this. I absolutely get it, I do see some radiologists list vast differentials and sometimes not even answer the proposed question. But clearly it seems that I will get out what I put in, and I intend to be as helpful as I can in honing in on a differential for my referring physicians. Thanks everyone!

 

[Psai]

No doubt, radiologists are very important in almost every aspect of medicine. Their final say is the equivalent to having life insurance.

As others above have stated, it's easy to catch the obvious but it never hurts to have an experienced well-trained eye.

White coat investor tells me that life insurance is basically a scam

 

[Doctor4Life1769]

Why was he banned?

 

[shoal]

Ummm no that is not what wci says. Term life insurance is ok is his recommendations. Need to read his blogs closer

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[Raryn]

White coat investor tells me that life insurance is basically a scam

Whole life insurance is. Term isn't.

Now back on topic: I can read a CXR moderately well, see an infiltrate or a large PE on a CT chest, find free air in the abdomen, see a head bleed on a noncon CT, and a few other big things. These are important skills to have in the acute setting, because radiology reads (even with a dedicated nighthawk) do take time.

That said... I don't have the training to see subtle things. Even after I get subspecialty training an am an expert in looking at organ XYZ, the radiologist is still necessary to look at the whole image to confirm my findings... and see whatever is incidental that I might not have paid attention to.

Look at the development of cardiac CT or cardiac MRI for example. Cardiologists can (and do!) read these studies primarily, and are very comfortable with the cardiac portions of them. In fact, with all of their experience with cardiac physiology, I'd agree with their camp that they're better at reading those studies... except that the cardiologist is much more likely to miss something like the incidental lung nodule found, or the skeletal abnormality noted, or whatever else. Even the most confident cardiologists generally have a radiology over-read for that sort of thing. No one else has the time to be comfortable with all portions of the imaging.

 

[jazzman84]

For all the bloviating you hear about surgeons etc. reading their own studies, you can be damn sure when they are named in a malpractice suit they will claim "the radiologist never told me about the pancoast tumor partially visible along the margin on that shoulder MRI!" That's why you always document communication with the referring provider about critical findings, because interpreting the study correctly and putting it in the report isn't sufficient in today's medicolegal environment.

If people's egos are big enough that they have to claim expertise about a field for which they have no formal training and decide management without noting the expert impression, then it makes no difference to me and it's not my license on the line. I do my job well and know I add value. The best clinicians are aware that their knowledge has limits, as does everyone's.

And yes, I agree that laundry list impressions are useless and something I see more in the older generation of rads, most of whom didn't have any formal clinical training outside of med school.

I'm also highly skeptical about most cardiologists' ability to interpret CT/MRI, especially with no formal training in MRI physics. If it was me or my family, you can bet I'd get a read from a body/cardiac rad.

 

[meister]

To be fair, the cardiologists I have worked with did imaging fellowships and did well with the limited nature of cardiac CT or MR.

I read out TTEs with them and with our ultrasound skills could easily see us reading those, though that ship has sailed.

 

[maxxor]

And yes, I agree that laundry list impressions are useless and something I see more in the older generation of rads, most of whom didn't have any formal clinical training outside of med school.

It is important to remember that Radiology did not require an internship until around 1997 or so, meaning that many people who graduated residency as recently as 2001 had no clinical training beyond 3rd and 4th year of medical school.

 

[themockjock]

I'm a CTS resident and we spend a month with the cardiovascular radiologists going over cardiac and great vessel CT as well as some MRI.

Our surgeons read their own TEVAR stent protocols, TAVR studies, etc. mostly because they understand the requirements of the different stent grafts, valves, etc. in a clinical setting that the radiologists do not (How much of a proximal landing zone do you need for a GORE TAG vs Valiant stent graft?). So, from an operative planning standpoint most of the reading is done by the surgeons.

What the radiologists are really invaluable for (for us) are two-fold, I think: 1) the subtle findings that can mean the difference between an emergent, high-risk 3am operation vs not (i.e. is that pseudoaneurysm leaking? Is that really an ascending dissection flap or motion artifact because the OSH didn't gate their CT aortogram?) and 2) as has been discussed previously, findings outside of what we directly care about (I remember a case of a 50ish otherwise healthy guy who got a screening CT aortogram due to family history of aneurysm. He didn't have an aneurysm, but did have a liver mass that turned out to be a met from previously undiagnosed colon cancer that just happened to be caught by the upper abdominal slices of the CTA - if that were only read by the aortic surgeon, I can almost guarantee you that the liver mass would have been missed...)

 

[TypeADissection]

No doubt about it. Radiologists are great and are highly valued at my institution. Like any specialty, you have good ones and bad ones. A very minor few are clearly checked out and mailing it in. But the vast majority are wonderful, easy to access and answer questions and they can definitely help you determine the difference between an emergent operation at an ungodly hour vs not. Much respect.