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Radiologist, Image Thyself?


Is there a certain hypochondriasis that may lead some radiologists to pursue their own imaging, and would it change how aggressively they follow up incidentalomas on their own scans?

I have written here about my readiness to informally review imaging for family and friends. It serves a few purposes. They can see me as a safety net, potentially finding things that the official reading rad did not. I can also discount false positives or modulate the importance of what has been said (like reassuring someone about a 1 mm lung nodule).

I might give someone a preview if a formal report hasn’t been issued or reviewed by their referring clinician. I’m also a sort of “radiology whisperer” to translate rad report jargon into plain speak. Sometimes, if folks are currently imaged at facility A but months/years beforehand they gave me a CD from facility B to review, I can make comparisons that the rads at facility A will not.

You might therefore be surprised when I tell you that I have almost never reviewed my own imaging. That’s really just a technicality because I haven’t needed any. I’m a fortunately healthy chap, and I’m of a mind to not go looking for trouble if I don’t perceive any.

In fact, I found myself a little resistant when the cardiologist I mentioned a few columns ago suggested I might go for a coronary calcium scoring. Ultimately, I went ahead with it. The tech was good enough to give me a CD of the scan (that facility often tells people that they can see everything on their “patient portal,” but I like having a hard copy for my shelves). Like a med student who’s just heard that exam scores have been posted, I hurried home, popped the disk into my PC and was happy to see nary a pixel of trouble.

Aside from having other uses for my time (and the $100 I paid out of pocket), I had some reluctance for the scan due to its potential to reveal bad news. That is far from unique to me, but I am loaded for bear when it comes to such anxiety. In addition to the hypochondriasis common for us docs, my work in the past couple of decades has shown me all sorts of cases revealing unexpected nastiness. If it could happen to all those other folks, it could certainly happen to me.

On top of that, I don’t know how prevalent this is among other rads, but I have had more than a few bad dreams over the years in which I underwent imaging to reveal horrible things — advanced cancers, cyst-riddled kidneys threatening imminent failure, you name it. Put a mind through even a few episodes of such worry, and some is bound to linger.

To see absolutely nothing of the sort, and further to disprove some things I had self-diagnosed (I was pretty certain I had experienced symptoms of a hiatal hernia over the years, for instance, and if there was one, it’s not there now), put me in a pretty fine mood for a few days.

The whole episode reminded me that I had, in fact, undergone some unnecessary imaging back in the day. For instance, there was often a lot of downtime during mornings of weekend call shifts in my residency. Before the ER got hectic and inpatient transport started bringing folks down to the scanners, the techs and I did a lot of sitting around. One thing led to another, and for funsies, I would up with a couple of non-contrast MR of myself. Maybe because I was younger and felt less mortal, I had zero worry that anything scary would turn up. I was more curious to see what undergoing a scan was like and of course to have baseline images for future reference.

I did discover a couple of things, even if none of them were imaging-abnormalities. One was that even the noise of a scanner doesn’t do much to stop me from nodding off if I lie down for a few minutes, and snoozing begets some involuntary motion. My shoulder MR, for instance, was pretty degraded.

Another wasn’t really my discovery. One of our neuro attendings had previously pointed it out, but I totally agreed with him. Since you can’t bring electronics into the magnet, any time you spent in there was an enjoyable separation from your pager. When the department had needed some warm bodies to calibrate the magnet, he had volunteered for a bunch of sessions, and enjoyed being unreachable while they were going on.

There is some popular wisdom in medicine that one should not treat oneself (or loved ones). It makes sense for more than a few reasons, one of the biggies being clinical objectivity. I abided by the notion, perhaps more than most. When I discovered that colleagues would not uncommonly prescribe routine things for themselves or family/friends, I kind of recoiled. Was that kosher?

I came to believe that it was to a limited extent as long as it pertained to the small stuff, and one limited one’s action to things one knew about. Maybe it’s okay to give a Z-pack to your pal for his upper respiratory infection but don’t even think about writing some Epogen for your mildly anemic cousin Dr. Rad.

The same rationale can apply to rads looking at their own imaging except we (hopefully) know radiology more thoroughly than we do about, say, ID or hematology. It is still probably a good idea to defer on the big stuff, a la “Do I need more chemotherapy,” but for things like reviewing my coronary scoring scan, it is totally reasonable.

I would go a step further: For the small stuff, sometimes subjectivity trumps objectivity. I am the best authority on how aggressive I want to be for incidentalomas on my scans. If I am formally interpreting someone else’s chest CT and I see lung nodules, my recommendations pretty much have to address the Fleischner Society’s guidelines. For myself, however, I know I am less inclined to bother with follow-up scans. Small stuff more reliably means smaller consequences if I am wrong.

So, when I happened to see some TSTCs (too small to characterize lesions, statistically benign) in my liver at the bottom of my scan, I didn’t waste a moment thinking about what to do next. I did wonder if the official read and/or my cardiologist would say anything about working them up, and I was ready to reassure the cardio that I knew what I was doing in deferring. As it happened, they didn’t even mention the things.

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