Things That Are Not on Images

January 4, 2021
Eric Postal, MD

What if you report things that aren’t on the scan you’re given?

I’ve mentioned once or thrice in this column that I do not consider myself an intrinsically-brilliant radiologist. I’m no academician, I never took to research, and I’ve yet to invent any new gizmos or imaging techniques.

I do flatter myself that I bring more than a few things to the table, however. When it comes to churning through an imaging worklist, I have an ever-growing “bag of tricks” that gives me an edge. Some of those tricks boost my productivity, some limit my liability, and some, I daresay, make me a better physician.

My repertoire grows in various ways, the most important of which is keeping eyes and ears open as I witness other rads doing their thing. Certain behaviors stand out to me as being particularly useful, and I adopt them. (At the other end of the spectrum are actions so maladaptive, I promise myself that I will never do the same.)

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One of the good items harks back to my post-grad training or soon after. Another rad, reading a stone-CT, noticed that the patient had undergone an ungodly number of CTs within the past year for the same reason. He made a point of this in his report, emphasizing the patient’s cumulative radiation dosage and suggesting that it be kept in mind. The rad didn’t come right out and say, “Were all these CTs really necessary? Try an ultrasound, you quacks!” The message was, nevertheless, diplomatically conveyed.

When I add something like that to my bag of tricks, I’m not just waiting for precisely the same situation to recur so I can execute the same behavior. Encountering something nifty and new gets me thinking in ways I previously didn’t, and my mind eagerly looks for other ways to play with its new toy.

I’m pretty sure that stone-CT incident, thus, opened a new door in my mind, to the effect of “I can tell clinicians useful things that aren’t on the actual images I’ve been given to interpret.” Useful things that, from my perspective as a radiologist, I am uniquely suited to point out.

For instance, in scenarios like that stone-CT: Commonly, a given patient’s scans are ordered by two or more different clinicians, unaware of how frequently other docs have done the same. Some might not even have it on their radar that there are alternatives to CT for checking on stones. A radiologist reading the current scan, aware of prior imaging, might be the best suited to point this stuff out.

Analogy: You’re making your way through a crowded plaza (assume post-COVID society if this makes you anxious). If you were trying to get a sense of how many in the crowd were wearing red shirts, you’d only be aware of the people immediately around you. Now imagine you’re standing on a 5th-floor balcony, overlooking the area. That perspective gives you an advantage in the same way our access to the imaging record gives us a perspective that the “boots on the ground” referrers don’t have. Even when they have equal access to our databases, clinicians are often too busy with other things to do much digging. But, we are in a position to give this info to them on a silver platter.

I’ve taken this approach out a new door from time to time. It’s rarely a sudden, “Eureka!” moment. Rather, I’ll gradually become aware of situations where I can fill a void in my little corner of the healthcare system. One might just have come to a head this past week, but the ball got rolling years ago:

Similar to serial stone-CT patients, I’d noticed some folks would have brain scan after brain scan for the provided history of “fall.” Most frequently, there was nothing acutely the matter on the images – just the expected senescent patterns of atrophy, microangiopathy, etc. No change from prior, or the prior before that, or the one before that…

Of course, there are any number of reasons for elders to be more susceptible to falling, or assumed to have fallen (for instance, found on the floor without signs of trauma). But, how many of these patients are wrongly assumed to have nothing more significant underlying their falls? What if the referrers ordering these numerous scans don’t realize just how many episodes of falling there have been?

A patient might, for instance, have scans for falls ordered by a doc at a nursing home, an internist during a hospital admission, a neurologist at some other juncture, and multiple ER staffers in the area over a course of months. Any one of whom might be unaware of falling-incidents beyond the one that they, personally, are evaluating.

So at some point, it occurred to me to upgrade my baseline suspicion for subtle signs of normal-pressure hydrocephalus (NPH). Even with equivocal images, my awareness of multiple prior scans for falls might just make me include an extra line in my report, noting the number of falls in the past year or two as potentially meriting clinical consideration of NPH.

This past week, the thought evolved further: Even without imaging findings to suggest that particular pathological entity, I still might have something to offer in this scenario. What would any other conscientious healthcare provider do if they noticed a patient in their care was falling a lot? Hopefully not just rule out injury or other acute issues and, then, forget the matter.

Instituting “fall precautions” or a “fall-prevention plan” might prevent future episodes with more severe consequences. A comprehensive evaluation could include medication review, nutritional evaluation, targeted physical exam, etc. Even a home-visit to investigate environmental risks.

A quick glance at the literature tells me that “recurrent falls” are defined as two or more episodes in an interval of six months and should be evaluated for treatable causes. Maybe I can get that process started a little earlier for some folks by pointing out how frequently they’ve been imaged for falls, rather than just saying their images are stable with nothing acute.

Follow Editorial Board Member Eric Postal, M.D., on Twitter, @EricPostal_MD.