is an independent Radiologist/Neuroradiologist providing
diagnostic services to hospitals and outpatient clinics in
Michigan, Florida, and California.
Not so many years ago, you could diligently review a
contrast-enhanced brain MRI, including all standard sequences, by
perusing roughly 150 images. Typically, you had the referring
physician's request with pertinent history/information, as well as
the patient's prior films and reports. Today, because of higher
image resolution and additional scanning sequences added in recent
years, you may need to review more than 350 images when
interpreting a contrast-enhanced brain MRI. Similar technologic
advances mean hundreds more images to review for a combined chest,
abdomen, and pelvis CT study. In many institutions, there is still
incomplete integration of the radiology information system (RIS),
the hospital information system (HIS), and the picture archiving
and communication system (PACS), which adds to the time and
complexity of ascertaining patient history and retrieving prior
relevant examinations and associated reports.
While a standard "normal" report can still be quickly
dispatched, the greater anatomic coverage and detail now available
means that more abnormalities are discovered with a corresponding
rare opportunity to use the quick "normal" report. I can not only
see that 7-mm adrenal nodule on CT, but, in most instances, I can
also characterize it. When scans were collimated at 8 to 10 mm,
that 7-mm adrenal nodule usually wasn't discernable: Normal report,
on to the next case.
Today it requires more work to interpret each case. Given the
large annual national increases in imaging utilization along with
the diminishing reimbursement for each case, our case load keeps
expanding. There are more studies to interpret, more images per
case, more findings to report, and more need to make comparisons to
prior examinations. More and longer transcribed reports require
greater time for proofreading and correction.
Where can we find some relief? Shortcuts. There are a number of
acceptable and very helpful shortcuts for handling the massive
amounts of information we process. Prepared standard normal reports
and computer-aided diagnosis (CAD) can help. It is very helpful to
have a properly configured PACS that is fully integrated with the
RIS and the HIS, so patient history and all prior examinations and
reports are readily available. The capacity of PACS to link several
scan sequences from different prior studies or from different
imaging planes or sequences in the same study saves time over
trying to do the same with film. Having well-trained ancillary
personnel do some of the leg work of contacting physicians or
trouble-shooting computer glitches is helpful. These are some of
the appropriate shortcuts.
We can, perhaps, rationalize a number of less desirable,
possibly perilous, but nonetheless tempting work shortcuts. It is
possible to find a reason not to review every image in a study.
Perhaps, we may rationalize that there are simply too many images
in a chest CT for "possible pulmonary embolism" to take the time to
also carefully assess the included lung parenchyma for a pulmonary
nodule or for interstitial lung disease. After all, if the study
was requested to assess for pulmonary embolism, shouldn't that be
where we put all our effort? Can't we just skip or skim through the
lung windows? A CT angiographic study of the carotid arteries
usually requires 500 images and covers essentially all of the soft
tissues of the neck, the cervical spine, and portions of the chest
and head. Should we spend time worrying about all this other stuff?
If the referring physicians need a study of the chest, neck soft
tissues, cervical spine, or head, they can order a CT of the chest,
neck soft tissues, cervical spine, or head, right?
Rationalizations like these are most often clustered near the
end of the day. Hey, it's 4:30 and we've got to "clean up" these
cases before we leave. Memo from the top: "You must sign all of
your dictated reports before leaving work each day." Perhaps, I can
just proofread the report's impression for accuracy before signing.
That's good enough, isn't it? That will save lots of time. An error
in the history, comparison, procedure, or findings portions of the
report isn't really that important, is it? They probably won't even
look at that part. It's been a long day, and it's now past 6:00;
I'll just batch sign/approve these last 37 reports. I'm too burned
out to proofread them now, and our transcriptionists don't make
that many mistakes anyway.
Another dangerous shortcut is taking insufficient time to
correlate current findings with prior relevant studies. In the long
run, this does not save time and can cause harm to the patient. For
example, consider the chest radiographic interpretation of a 1-cm
pulmonary nodule within the right lower lobe with a recommendation
for a follow-up chest CT. As it turns out, the patient had an
abdomen CT 4 years earlier that documented that the pulmonary
nodule was a benign granuloma. The radiologist saved time-that
day-by not looking for and correlating with prior relevant
examinations. Now a problem is created that doesn't actually exist.
The patient receives the bad news that there is something wrong on
the chest X-ray that "could be cancer." An unnecessary chest CT is
scheduled a week later, and the anxious patient must take the
afternoon off from work. The test requires an IV, and the contrast
injection offers the potential for the rare extravasation, an
allergic reaction, an idiosyncratic reaction, or acute renal
failure. Also, don't forget to add exposure to a sizable dose of
ionizing radiation. So the radiologist who may have saved some time
interpreting the original chest film has now generated an
unnecessary chest CT that requires time to interpret and
unnecessarily stresses a patient.
Lastly, some radiologists have decided to change the
well-accepted American College of Radiology recommended format for
radiology reports and forgo the conclusion/impression portion.
Findings are dictated, sometimes mixed with differential diagnosis
and/or follow-up recommendations. While forgoing the formulation,
dictation, and review of a final impression will certainly save
some time for the radiologist, it will waste the referring
physicians' time as they try to figure out which findings are
important. Also, any radiologist who reads this report to correlate
the findings with later studies will need to hunt through the
entire report to determine the relevant information.
Some shortcuts used in doing our work can lead us down the wrong
path. It behooves us to strive for the highest quality to remain
the preferred specialty for medical imaging interpretation.
Radiologists must maximize their use of legitimate shortcuts:
- Have all available history in a single reference location on
- Engage PACS information technology personnel to help tailor
hot keys and hanging protocols.
- Confer with your radiologist colleagues who may have
developed efficient hanging protocols and hot keys for PACS.
- Have a radiologist assistant readily available to phone
reports or to track down a technologist or other colleague to
review a case.
- Review reports carefully for correct content and spelling.
Consider that an incorrect or missing word in any portion of your
report could, at a minimum, reﬂect poorly on the
quality of your service and could result in harm to the
- Refrain from rushing through any case for any reason.