Agraphia Medical Tragicomedy

17Nov/12Off

The Radiologist Dilemma

The other day, I had a kid come in with a pretty obvious forearm fracture.  I took a look at the xray, sedated the kid, reduced the fracture, splinted it, called orthopedic surgery for followup, and discharged the kid in about 20 minutes.  An hour later, I got a call from our radiologist.

"Hey, man.  I was just looking through some films up here in the reading room.  You know you've got a forearm fracture in room 18?"  Politely, I thanked him and said I'd look into it.

In the past, radiologists were a prerequisite to the interpretation of films, in part because of how the images were processed.  Before the electronic era, xrays were put through a complicated chemical exposure and then a lengthy drying process in the radiology department.  If needed, a "wet read" could be obtained by having a radiologist look at the film prior to the full drying process - literally looking at a wet film.

The term "wet read" still persists, although now it implies a preliminary or stat read.  Since images are instantly available on the computer after being taken, often this is an unofficial read by an ER doc or another specialty. Sometimes it is the opinion of the on-call radiologist who is looking at an xray or CT scan outside of their subspecialty, which then gets looked at by a second radiologist the next day.

This means that often xrays don't get a definitive reading until well after the patient has left the ER.  This leaves us ER docs to read most of our own xrays and sometimes even interpret CT scans if things are moving slowly. There is an entire fellowship in emergency ultrasound, cutting out the radiologists entirely.

For the most part, if it's not something complicated, I'm pretty comfortable reading my own films.  I also have the benefit of directly correlating the images with the history and physical exam. Here's a paper from 12 years ago showing only a 0.1% discordance rate between ER docs and radiologists when the ER doc is confident of their interpretation.

Now, this gets into some significant medicolegal liability issues (and more than a few turf wars on both sides) that I don't have time to discuss here, but suffice it to say - medicare/medicaid and insurance companies are not super excited about paying two doctors to look at one xray.  One way or the other, I suspect change is coming.

I suspect that eventually radiology will turn into a centralized, 24/7 field. It's a growing concept called tele-medicine, comprising radiologists, pathologists, and other specialties whose intellects but not physical presence are needed in many locations at once.  With the exception of interventional radiologists who need to be on-site, all radiologic images will be reviewed by large groups not bound by hospital or timezone. I'm honestly surprised it hasn't happened already.  Think of it as the Netflix vs. Blockbuster of medicine.

I envision a huge group of radiologists, comprised of every radiologic subspecialty.  Need an xray of the knee read at 3:15 AM?  You'd better believe there's a trained musculoskeletal radiologist reading it within 5 minutes of it being performed.  Do things on a massive scale and the vicissitudes of any given hospital's patient volume gets washed out in the flood.  To some extent this already exists, but for the most part it's purely night coverage until the local radiologists put the official stamp on the report in the morning.

Radiologists aren't going anywhere - they are invaluable at picking apart small subtleties I will never see without their training and their high-end, high-contrast monitors in dark rooms.  The field as it exists now, though?  I suspect that will change a lot in the years to come.

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  1. Enter telemedicine. Send all your images to India and have it read by a radiologist there. You could even speak to the guy directly 😀

    I wonder what they will call these places… can’t call them “call centers”. How about “Rad centers”?

    • It’s not that simple. Any physician officially interpreting a film in the states must be US board certified. They can live and interpret images in India, but they will still charge comparable rates or incrementally less because they’re credentials didn’t come cheaply.

      • I think it probably means, that radiologists can go to some place with a different time zone, nice beaches and report images from the retina display ipad, whilst sunbathing. 😛

        More seriously, telemedicine is picking up in Australia its used more to get specialist input if your working in a rural area. Specialists can videoconference in to take history and see patient being examined, then review any imaging. This is really useful with things like stroke thrombolysis where you want a neurological opinion before you thrombolyse.

  2. They already have this type of radiology setup here in the Twin Cities. They interviewed a radiologist on the news who has a viewing room in his house. He gets images from 5 hospitals and interprets them over a HIPAA secure server. He rarely has to report to any of the hospitals in person. He had a darkened room in his house with several large high res screens. Seemed like an ideal way to work, never even had to get dressed if he didn’t want to.

  3. Interesting. Radiology is a field I’d consider, although I’m not sure that working in a dark room all day alone would be all that exciting.

  4. I am a teleradiologist. What he has to say in this article has long since happened, although we take a little more than 5 minutes to get a read to them. Like many, I give final reads, almost never a preliminary. Obviously, we need dark rooms to read in. Despite being in Hawaii, I work in the dark. While any doctor who has put in the effort can do a decent job of interpreting films (90+%), most overestimate themselves. I know ER doctors and cardiologists think that they are quite good at it. However, as I have worked in places that over-read these, it is quite scary how large of findings are missed, despite being trained by non-radiologists.

    As far as location, the government requires that we be on US soil to read the cases. That is actually a good thing. US doctors reading US studies is a plus, as there is a better understanding of the patient population.

    As for Med School Odyssey, don’t go into radiology. The job market is tight and the government keeps slashing reimbursement. In fact, like any good doctor, I recommend that you drop out of medicine now. You will thank me later.

  5. Dr. Ben,
    very interesting opinion, as this was exactly what I wanted to do (and in fact pretty much the sole reason I went back to school to complete med prerequisites)–interpret films, not necessarily from Hawaii, but from any location. I wasn’t thinking of money or job market primarily, just the actual job of interpreting films really appealed to me. I thought it might be something like interpreting spectroscopy.
    Would you by any chance be willing to email me (or just reply here) and let me know why you don’t like this field or why you would advise people not to go to med school?
    I haven’t yet taken the MCAT and am not sure if I should go back or not.
    postbacc.medical.2013@gmail.com
    I would really appreciate it.

    • EDIT:
      I just wanted to add, if anyone read this that of course I know there’s a considerable difference between interpreting nmr spectra and interpreting films. but that sort of analytical interpretation was what interested me, after shadowing a cardiac mri doc.

      • something else, or done the work. So I have done it.And it is such a pathetic lteetr!In what follows I have taken each sentence apart, where there is anything of substance to analyse. I hope that it is straightforward. I had it all nicely arranged with italics and bold, but transferring it to here robbed my text of all that neatness.Paragraph 1 Do you consult your dentist about your heart condition? I have dealt with this false premise above, and a dozen or so other posters have done so as well.Paragraph 2 Sentence 1 The lteetr by the 16 is e28098the climate-science equivalent of dentists practising cardiologye28099. Since the premise is false, this conclusion has no merit.P2 S2 e28098While accomplished in their fields, most of these authors have no expertise in climate science.e28099 Really? What is e28098climate sciencee28099? I would call it a quarry, into which miners bring the skills they have developed in their own disciplines. There were no undergraduate courses in climate science when I surveyed this field in 2008, and few at the graduate level. Virtually no one 40 years or older can have such a degree, and in any case what are the fields of expertise of the 38? This is a bogus argument that collapses as soon as it is inspected.P2 S3 e28098The few authors who have such expertise4988 are known to have extreme views that are out of step with nearly every other climate expert.e28099 This is an assertion that comes without evidence of any kind. It is based on the bogus claim that there is a scientific field called e28098climate sciencee28099 whose boundaries include the 38 but not most of the 16. No evidence is given.P2 S4, 5 and 6 These three sentences serve to introduce the implication that the 16 are likely to think that HIV does not cause AIDS, and that smoking does not cause cancer; they are a smear and not worthy of discussion.P3 S1 e28098Climate scientists know that the long-term warming trend has not abated in the past decade.e28099 It is wonderful that they know this, because on the evidence the long-term warming trend has levelled out if it has not stopped. Both my statement and the one in italics rely on the inspection of data averages, whose formulation is subject to a large amount of error, some of it non-random. The sentence is more a statement of belief than of fact.P3 S2 e28098In fact, it was the warmest decade on record.e28099 This may be true, though I have no faith at all in averages of temperature that are expressed to three decimal places, notwithstanding that there are thousands of observations, for the reasons given above. In any case, since the world seems to have been warming in an irregular way since the Little Ice Age, this statement has little meaning.P3 S3 e28098And computer models have recently shown that during periods where there is a smaller increase of surface temperatures, warming is occurring elsewhere in the climate system, typically in the deep ocean.e28099And what observations support these model predictions? None is mentioned.P3 S4 e28098Such periods are a relatively common climate phenomenone280a6e28099 Mr Trenberth appears to be having his cake, and eating it as well.P4 S1 and 2 e28098e280a6what one of us, Mr Trenberth, actually meante280a6’I guess most of us have read the e28098travestye28099 remark. He is entitled to say what he thinks it meant. I would have to say that the ordinary reading e28094 that it is an embarrassment to the Team that the world is not warming as it should e28094 is clearer and more obvious.P 5 S 1, 2 and 3 e28098The National Academy of Science (set up by President Abraham Lincoln) e280a6 and many learned academies all tell us that e28098the science is cleare28099. Wow! What a wise old bird Lincoln really was. This is the argument from authority with a century and half of wisdom behind it. Trust us: we speak with all this contemporary authority, and President Lincolne28099s as well.P6 S1 e28098Research shows that more than 97% of scientists actively publishing in the field agree that climate change is real and human caused.e28099 Now which research would that be? What did they agree to? Who asked them? How was the question phrased? Asking people questions in surveys is one of my fields of research, and ite28099s a new figure to me. I understand that Lawrence Solomon, who likes to follow these things up believes (and I quote him) that it e28098stems from a 2008 mastere28099s thesis by student Maggie Kendall Zimmerman at the University of Illinois, under the guidance of Peter Doran, an associate professor of Earth and environmental sciences. The two researchers obtained their results by conducting a survey of 10,257 Earth scientists. The survey results must have deeply disappointed the researchers e28094 in the end, they chose to highlight the views of a subgroup of just 77 scientists, 75 of whom thought humans contributed to climate change. The ratio 75/77 produces the 97% figure that pundits now tout.e28099 You can read the rest in his column in the Financial Post. I really love e28098research showse28099 with no mention of which research we are talking about. Perhaps Solomon got it wrong, and it comes from some gold-standard PhD thesis from Yale. Be nice to be able to study it.P6 S2, 3 and 4 Let me partly paraphrase the concluding flourish. The Republicans would be reckless to e28098 ignore the enormous risks that climate change clearly posese28099. And shifting to a low-carbon economy e28098could drive decades of economic growthe28099. Finally, we return to the beginning: e28098Just what the doctor ordered.e28099If I compare the two lteetrs, that of the 16 is much more measured and cool. The response is, as I said at the beginning, is pathetic, and weakens my already shaky confidence in the truth of anything the Team members say.Of course, my own bias could affect my reading of the two. So I would welcome correction where I am in error, and debate where there is more that I could have said.


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