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Now Look What You Did!


The discomfort of a positive finding.

It’s getting close to 20 years that I’ve been looking at diagnostic imaging and offering my sense of what it shows. At first, to senior residents, fellows, and attending physicians in my radiology residency program, but for the most part to referring clinicians and even patients.

The only constant is change, or so they say. It therefore stands out to me when something remains fairly constant for a decent length of time. Example which inspires today’s column: I often feel distinctly uncomfortable about making a positive (that is, bad) diagnosis.

It’s not just a matter of having a deep and abiding empathy and sense of goodwill towards the patients whose cases I’m reading (or, indeed, their clinicians who will ultimately have to deal with the diagnosis I’ve made).

I think it’s more a matter harking back to childhood: Having broken something, or otherwise erred, bringing it to the attention of an adult carried a certain sense of shame at having done so. Not to mention worry at the displeasure of said adult, and/or consequences of same. Even just being the discoverer (not the cause) of something untoward and reporting it carried the risk of being blamed for it. Or just witnessing the unpleasant negative reaction of the relevant authoritative figure.

Indeed, it’s not uncommon for us, encountering bad findings and communicating them, to experience backlash. A surgeon who really didn’t want to have to come into the hospital to deal with a postop complication, for instance, or an ER doc who was all set to discharge a patient but now has to call in consultations, do more bloodwork or imaging, etc. With the right amount of vexation, many of our clinical colleagues are capable of “shooting the messenger” (that is, us).

There’s also the factor of extra work or hassle for having come up with a positive diagnosis. A negative study, or one with only minor abnormalities, typically doesn’t require us to do anything more than signing a report and moving on to the next case. Finding things like a new stroke, bleed, bowel perf, etc. starts us down the joyless path of trying to get a responsible clinician on the phone so we can document that we verbally communicated our findings. (Paling in comparison to the cascade of events upon identifying potential cases of abuse.)

Sometimes there’s the added bonus that our efforts are not appreciated: Having finally gotten a patient’s doc on the horn at 3 AM to tell of the subdiaphragmatic free air we saw, we are rewarded with a chewing out that of course there is free air, the patient is freshly postop (not that anybody saw fit to provide that information in the clinical history for the CXR so we would know).

At times, it feels like a personal defect that I haven’t been able to expunge this discomfort. That is, at some point in the past almost 20 years, I feel like the discovery of a significant imaging abnormality should have stopped prompting in me a sense of unease or even dread. Do other rads have this issue? I wonder if another couple of decades will do the trick.

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