Navigating the Radiology Conundrum of Reading X-Rays When Follow-Up Imaging Has Already Been Done


When you’re asked to review an X-ray for a patient who already had follow-up imaging, do you consider the results of follow-up imaging or evaluate the X-ray with fresh eyes?

I have been a regular watcher of the Dr. Who TV series for much of the current millennium. I never got into the older stuff, and I might just be bowing out after the last couple of seasons. Still, I have put in enough time that I probably qualify as a fan.

For those unfamiliar with Dr. Who, time travel is a central theme of the show. Sometimes it makes more sense than others. Given that actual time travel is not a real thing (as far as we know), the show can get away with making stuff up as it goes along. Who's to say it is any more or less accurate than the Back to the Future franchise, or anything else dabbling with the concept?

Viewers aren't exactly watching such things for technical pointers. These shows or films are usually more about having fun with the concept, or provoking thought. Maybe I can thank that for my recent awareness that I have, in a way, been dabbling in radiological time travel.

Most of us do to a certain extent. Unless everything you do is in real time, like interventional stuff or good old-fashioned barium slinging, the images you are interpreting are a snapshot of the past. You might phrase your reports in the present tense, but your descriptions of pathology (or lack thereof) are only accurate as of whenever the patient was being imaged.

That doesn't matter so much if you read stuff in the STAT setting. If you have a super low turnaround time and your referrers see your report right away, everything is essentially happening "now." It's also not a big deal for non-emergent things like routine screenings or periodic surveillance of slow-moving pathology. If you read a study a couple days after it was done, and the referrer sees your negative report a few days after that, all is well.

It is more troublesome when some clinician suddenly wants results on something that was done a while ago but didn't get read yet. Another scenario may involve a routine exam from a couple of days ago that turns out to have an unexpected acute abnormality that warranted urgent action. It's as if a villain got ahold of time travel and used it for nefarious means. The good guys now have to scramble in an attempt to make up for the lost time.

My own recent time traveling radiology has been much more benign. I mentioned in recent columns that I have been doing some "internal moonlighting" to help with a perpetually accumulating glut of X-rays. In a typical day, many of the films I see are of patients who already went on to have follow-up studies via various modalities.

Sometimes, the subsequent X-rays have not been read yet either, and I will bundle them all together for a report that talks about how things have changed or remained stable as the hours (or days) went by between studies. Alternatively, other folks have already read the more recent stuff. I then get to generate my report knowing what happened in the future of the films I'm looking at.

I have considered the value of being dogmatically and intellectually honest about it. In other words, I would blind myself to what happened afterward and just give a standard interpretation of the past-tense X-ray in front of me. That would surely be the right thing to do if I were reading for pure academic or research purposes (or, God forbid, legal ones.)

That doesn't really help the referrers or patients though. The more actionable information I give them, the better. For instance, if I see yesterday's right mainstem bronchial intubation but I know that today's CT shows proper retraction, I don’t need to ring up the referrer to say the tube has to be pulled back.

For that matter, I should say in my report that, yes, the tube was malpositioned on that film, but it was already taken care of on the subsequent scan. Otherwise, some nurse getting ahold of my X-ray report and not knowing about the CT might dutifully page her house staff to tell them about a tube that needs no adjustment.

The thought has occurred to me that I probably spend too much time and effort on a lot of these past-tense films. My reports aren't exactly novels, but I'm still generating verbiage that somebody's going to have to read through just in case … and they already know what subsequent imaging showed. If I say nothing new, I am wasting my time and theirs. I might do better for everyone involved if I just had a macro like: "Study presented for interpretation after other imaging has already occurred. Please see report of subsequent exam."

Of course, I can't know that my X-ray from the past showed nothing new or important without going over it. There is always a chance that I will see something a more recent study missed because of technical factors (or error on the part of another radiologist). It might just take me being the equivalent of a time traveler from the past to tell present-day people about a subtle fracture or tiny pneumothorax.

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