Cullen Ruff, MD

Radiologists may discover more on CT scans, and feel more connected to patients, when patients' photographs are included with the CT images, according to a study presented at the last RSNA meeting by Israeli researcher Dr. Yehonatan Turner.

This research is unique and intriguing, and it was featured in major newspapers. Photo inclusion could become a regular part of medical imaging and has no potential downside to the general public-until, like a radiologist, one looks deeper.

Imagine yourself, briefly, in the position of the patients, few of whom happen to carry glossy snapshots. Is it not miserable enough to lie sick on a stretcher in a short gown, seeking an emesis basin between blood draws, without wondering if the ER photographer got your better profile? Would we rather be captured with our bruises and cuts still open, or proudly displaying fresh stitches? You get the picture, literally, and it's not pretty. But it could become immortalized in your digital medical record. Talk about a bad hair day. It makes a DMV visit sound like a professional sitting.

Lay the privacy issue and vanity aside. Discovering more incidental findings on a study sounds great-but is it always? If radiologists detect more injuries, cancers, infections, even kidney stones, that information is relevant, likely affecting treatment outcomes. However, we know that many incidental discoveries are inconsequential. Most of us have a cyst, a small benign tumor, or a variation of normal anatomy we would otherwise never know about. A good radiologist is expected to find these things, recognize them for what they are, and recommend appropriate workup, which may be none at all.

What's the problem? Sometimes it takes one, or several, follow-up studies to confirm that a lesion is just a cyst or benign growth. Sometimes benign tumors still require needle biopsy to exclude cancer. Finding more small, incidental discoveries means more expense, more radiation, and more invasive procedures with their inherent risk, all to prove that something harmless is indeed harmless. With these comes the further cost of unnecessary but inevitable patient anxiety. Suddenly the benefits of detecting additional subtle findings become more complicated.

Doctors in Turner's small study felt more empathy for the patients scanned after seeing their photos. Fair enough. We are human, and there is always room for compassion in healthcare, even for those of us who often work behind the scenes. This does not imply, however, that the absence of a photograph completely shelters us from patients' misery and erases all compassion. Fractures on x-ray images will always look painful to me. Strokes look debilitating and tragic. I've diagnosed thousands of cancers, and they still look ominous and frightening, making me wonder what the future holds for these unfortunate people.

When we diagnose, we envision pain, limitations, complications, sometimes mortality. I'm grateful every day to be on this side of the x-rays. Like most in our field, I still work to maintain a connection to the patients I serve, trying to be not only accurate and thorough, but empathetic and effective. Still, it never hurts to be reminded of the individual being imaged, so if compassion is improved with a photo, say cheese.

And yet, is there no benefit at all to some emotional distance in medical care? A trauma surgeon who is competent and decisive can first please put me back together, then hold my hand. Pathologists diagnosing cancer under the microscope best demonstrate their compassion with their thoroughness and accuracy, given the impact of their work on the patient. They need not weep doing their job, just be confident in their diagnosis.

Radiology is one of the more objective medical specialties. Doctors interpreting CT scans see plenty inside, but we cannot directly see skin color, religion, ideology, or socioeconomic class. Sometimes we get so engrossed in a liver or pancreas that we briefly even forget whether the patient is male or female, until we return to body parts that remind us. Would a photo remove this impartiality, making interpretations less objective? Would we be more concerned or more thorough studying some patients than others, based on how they look on the outside? I hope not.

Dr. Turner's investigation raises valid clinical questions, and it should be commended. If further study determines that patients, technologists, and radiologists are overall better served when scans include a photograph, we will surely comply. A CT scan may already contain up to several hundred images-I just hope that adding one more does more good than harm.

Cullen Ruff, MD

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