Just How Abnormal Is It?

June 10, 2016

Is there a reason for grading in imaging?

I’ve changed jobs a few times. In our line of work, that’s not exactly a fluke-postgrad training, alone, can put a rad in three different hospitals as a matter of course (internship, residency, fellowship). Having thus been part of three facilities in six years, I hardly consider it outre of me to have had three full-time gigs in the subsequent decade...if anything, it shows I’m staying put for increasing stretches of time.

One thing about changing jobs within a given field (indeed, a frequent reason for doing so) is encountering different ways of doing the same thing. Some better, some worse, and others defying clear cut deposition into either category.

Upon beginning my now-five-year stint in teleradiology, a perfect example was the routine grading of all interpreted imaging studies on a scale of abnormality. That is, in signing off a report, you’d be greeted by a pop-up window which required you to categorize the study as (I paraphrase) Normal, Minor Abnormality, Major Abnormality, Major Abnormality (Attention Needed), or Major Abnormality (Physician Notified).

At first blush, a rad who has not previously had to do this might greet the new task as an unwelcome irritant. Yes, it takes only a couple moments’ thought and two extra clicks of the mouse, but multiply that by a few hundred cases and it adds up to time and effort that could have been directed elsewhere. Further, without a clear-cut explanation of why cases need such pigeonholing, a rad might conclude that this is yet another intrusion imposed by outsiders who, themselves, do not (and may never have) read imaging studies. Bureaucrats, regulators, administrators, etc.

Happily, I skipped over this phase of adaptation, as I had encountered this abnormality-grading scheme somewhere before. Maddeningly, I could not recall where, still cannot, and upon asking around have failed to find others knowing the origin of this practice. If any readers out there can enlighten me, I’d sure appreciate it-maybe name a future blog after you or something.

Nope, I just went ahead and did the extra clicking. It’s a funny thing about such routine matters; however simple they may be, even if you spend all of a second thinking about them each time they arise, a second per case adds up to a decent volume of thought.

Such thinking can be inquisitive: Who actually sees what category I’ve assigned to a case? And do they do anything with the information? Would it be discoverable and potentially problematic in a medmal situation? Should there be QA consequences for rads who enter the wrong abnormality-category?

It can be enterprising: This is a lot of data being compiled, and probably can be used for all sorts of things: Research, feedback for clinicians and facilities (Dr. X orders an unusually high proportion of Normal head CTs…maybe he needs to order more judiciously), and higher-order stuff like industry trends in imaging utilization. Perhaps even the backbone of an automated result notification system (a referring clinician might, for instance, have a cellphone app that alerts him whenever a study he’s ordered receives a Major Abnormality report).

Or simply philosophical: What, exactly, is Normal? Does a 3-degree scoliotic curvature that might be positional count as a Minor Abnormality? How about a postsurgical patient with altered anatomy-is he forever consigned to the Minor Abnormality category, or is his post-op configuration now to be considered his new Normal? How about a study that’s otherwise normal but the patient happens to be morbidly obese (or looks cachectic)?

Such thinking occasionally circles me back to the fact that, while I have seen this abnormality grading system before (somewhere!), in the majority of my work environments it has not been utilized. Suggesting that either: 1) It’s a good idea that hasn’t caught on just yet, or 2) It’s a bad idea, or at least not good enough to motivate the industry for universal adaptation.