is the Editor-in-Chief of this journal and a Professor of
Radiology, Diagnostic Imaging Department, University of Maryland
School of Medicine, Baltimore, MD.
Why isn't it mandatory within the certification requirements of
The Joint Commission that requests for all diagnostic studies be
accompanied by the current clinical signs and symptoms that
prompted the study to be obtained? There are a zillion (or some
other really big number) rules about how far boxes need to be from
automatic sprinklers, how bottled gases need to be arranged, and so
on. What is it about requiring meaningful clinical information on
imaging tests that makes it forbidden territory for mandatory
Picture yourself as an internist (nothing personal against
internists; some of my best friends are internists) who is seeing a
patient with abdominal pain. You have several potential approaches
to deal with the situation.
- Interview and examine the patient. Assess vital signs while
learning the quality, location, frequency and duration of the
pain. You may ask about potentially pertinent medical history,
perhaps obtain some basic blood work, auscultate for bowel sound
and test for guarding, rebound, etc. (all that medical school
stuff). Next, you assemble all that data and formulate a
differential diagnosis. Then you decide if further testing is
needed to establish or eliminate the most likely diagnosis. Next,
request the imaging study, providing keypositive and negative
information or consult with the radiologist (you always wish you
had gone into radiology) to discuss the patient's findings and
arrive at the most efficient imaging work-up, if needed.
- After performing a history and physical you request the study
that you believe is most appropriate, providing minimal clinical
information on the request, i.e. "abdominal pain."
- After performing a history and physical, you request the
study you believe is needed and provide "rule out" appendicitis
as the indication. This diagnosis may be your leading diagnostic
consideration or just something to exclude because it's serious.
The clinical assessment may not point that way at all, however,
the diagnostic imager will focus on assessing the appendix and
perhaps spend less time and attention on other areas. That's a
By the way, why is it that someone would want to "rule out"
their primary diagnosis? I would think you would want to verify it.
Having it ruled out all the time would force you to question your
diagnostic skills. But I digress.
- You take the symptoms off the triage nurse's notes, glance at
the patient from the foot of the bed to verify life and request
multiple studies to cover any potential abdominal pathology. The
order in which these studies are performed is by luck of the
draw. Have the nurse write "pain" in the clinical information box
- Never see the patient, have the nurse order tests for
whatever body part hurts and one joint above and below, and offer
"other" by way of clinical history. These are the patients whose
primary physicians can never be found and everyone else you reach
denies knowing or wanting to know of the patient's existence.
Sometimes this circumstance requires you to write a note about a
critical finding and tape it to the patient's chest. You can also
mention to the patient that they have an acute aortic dissection
on the off chance they will remember to mention this to any
medical personnel who happen by.
Of course the entire scenario described above is hyperbole. I
So why is it that expensive imaging studies, which require
patients to be injected with contrast materials-or swallow
obnoxious liquids or perhaps even get these liquids instilled from
the opposite direction-in preparation to receive a walloping dose
of ionizing radiation onthe order of a smallish solar-mass ejection
get requested with missing or misleading information? Performing
these studies is serious business and should be requested with some
consideration for cost, appropriateness and the risk-benefit ratio.
Of course, pertinent and factual clinical information should be
provided to the interpreting physician. Some nonradiologists
interpret studies quite well, but I would never bet on one over a
board-certified radiologist, not for any patient I cared about.
When the topic of useful clinical information came up recently
with some visiting radiology residents to my program (of course no
resident from my institution was present) I heard some interesting
examples of the less than in-depth clinical information provided on
requests. Here are just a few:
- Feeling poorly.
- R/O fever.
- GI attending wants study.
- Pain (total-body CT requested).
- Patient has lipoma on back. Patient requests metastatic
- Patient stubbed toe (total-body radiographic survey
- Bumped knee on fire hydrant, total-body radiographs
requested. (I am glad they included the fire hydrant.)
- History of epilepsy, R/O pneumonia.
I'm certain the reader can supply many more such examples.
Please send them my way as I am trying to build a world-class
collection. Information technologists tell me that newer
order-entry systems require clinical information before an imaging
study is "ordered." Fine, except someone who actually knows the
patient should enter that information. It must be accurate and,
even better, should ask a specific question for the study to
resolve. One begins to doubt concurrent requests on 30 intensive
care unit patients who all have "atelectasis" for their clinical
information. All such foolproof systems have workarounds anyway.
It's sad that such measures are needed.
OK, now all you hospital regulators and risk managers out there
get cracking on this problem! We have all seen more than a few
imaging study interpretations messed up as a result of missing or
misleading indications. If the study is important enough to
perform, it's important enough to be requested correctly. After
all, we're here to help the patient, not challenge the radiologist
to read shadows in a clinical vacuum.
By the way, it might not be such a bad idea to leave this
editorial lying around where your referring docs just might happen
to run acrossit.