Snappy Answers to Stupid (Radiological) Questions

December 9, 2019

When radiological images present familiar, perhaps, obvious questions.

It never ceases to amaze me how a holiday-shortened workweek can seem paradoxically longer than a normal five-day affair. Nibble away a Monday-say, for Memorial or Labor Day, or better yet Thursday and Friday (thanks, still-sorta-new job, for being my first gig that let me experience Thanksgiving the way normal people do!), and somehow, the remaining days just seem to drag on that much longer.

So there I was, going through a typical bundle of cases with eyes towards my upcoming break, and a brain scan bore the all-too-familiar “R/O TIA” as the reason for exam. Far from the first time, I fantasized a world in which I could just dictate “Imaging cannot rule out a transient ischemic attack. Thank you for this fascinating consult.” Next case.

(Of course, if the study had actually shown a stroke, it would have ruled out a TIA in the same way one might rule out a benign tumor by diagnosing a rip-roaring malignancy. But let’s not quibble; the study was normal, and the only way to know if there had been transient neurological signs/symptoms would have been, to coin a phrase, correlating clinically.)

Such imaginary retorts would probably be with me regardless, but I’ve got to imagine I’m more predisposed since my childhood was enriched by Mad Magazine’s recurring feature, “Snappy Answers to Stupid Questions.” For readers unfamiliar, I, first, offer my condolences for being shortchanged on your youth, and, then, suggest a quick Googling of the phrase for some catching up.

Times have changed, and some of the humor might be dated, but I suspect folks will always have a deep-seated itch that gets satisfyingly scratched by the notion of giving blunt, maybe-sarcastic answers to questions that had no business being asked. This is especially true when actually giving such answers would be maladaptive, if not catastrophic, to one’s relationships, social standing, and career.

Ask a bunch of radiologists about the dumbest “reason for exam” questions they’ve encountered, and many of them will probably be similar…heck, I’ve mentioned them more than a few times in this column over the years. One of the side-effects of reading an ever-increasing number of studies per day is that your sample-size grows to the point that trends are much easier to identify.

This diverges from another phenomenon about which I once wrote: Cases with entirely legitimate histories that 99-plus percent of the time turn out to have virtually identical readings. For instance, in my residency we noticed that just about all CXRs for “chest pain” in relatively young patients would be stone-cold normal. With such cases, you might know, with nary a glance at the images, what the interpretation will be. But, the clinical histories themselves are reasonable and don’t lend themselves to “snappy” retorts.

There are a handful of others in the same boat as the “R/O TIA” mentioned above, where the provided history is more or less irrelevant to the exam. “R/O pain,” for instance, practically begs for a radiological impression of “Cannot rule out pain-suggest you ask the patient how he’s feeling.” Same for “R/O pathology,” really, since even a head-to-toe scan isn’t going to exclude cyclothymia or a viral upper-respiratory infection.

Another one of my favorite peeves is “Follow-up.” That’s it; no mention of what we’re following or whether it was seen on another imaging study. With that (lack of) information, literally anything I see, or don’t see, could be of importance. If I don’t see anything, does that mean there was something that has resolved? Or that someone else overcalled on a prior study? Or, maybe, I’m missing the abnormality?

Suppose I do see something, like a pulmonary nodule (have I ever blogged about how much I have come to despise that overused word? If not, I’m sure I eventually will). Well, hey, we’re following something – God knows if what I’m looking at is it. If so, I have no idea if it’s new, stable, bigger, or smaller. I can be as descriptive as I like, but it hardly matters because I’m going to be asked for an addendum when someone, after the fact, gets me prior imaging or at least a description of the same. I might as well just rubber-stamp all “follow-up” studies with “Temporary Impression: Follow-up performed. An addendum will follow this follow-up when relevant information is received.”

My absolute favorites are when the clinical question is more specifically irrelevant to the patient, because it pertains to organs he or she either doesn’t have anymore, or never did in the first place, such as “R/O cholecystitis” in someone who’s had the gallbladder out or “appendicitis” in a post-appendectomy patient. There are any number of ways one could have fun with this.

I can imagine going on at length about how the appendix isn’t there, and offering all sorts of possible scenarios about how its absence came to be: Removed as part of some other surgery in the area, atrophied into nothing, consumed by intestinal parasites, taken for study during an alien abduction, etc.

Then, maybe two paragraphs later, mentioning that, oh, yes, it might have been removed at some point because there had, indeed, been appendicitis. So, no, I can’t rule out that appendicitis was present once upon a time…oh, you surely weren’t asking whether this patient without an appendix had appendicitis NOW? I won’t insult you by answering a question we both know you’d never ask.

Thanks, again, for this fascinating consult.