5 things that only a radiologist will know and understand

2020 10 07 16 53 2439 Maskell Giles 20201007165641

Good clinical practice demands that we share our knowledge as appropriate to support patient care, but despite my best efforts, there seem to be some things which only a radiologist can understand.

One of the characteristics of a profession is that its members possess and share a body of knowledge -- some of it explicit, some of it tacit -- which is not held by non-members. Obviously, as a result of our training, radiologists possess skills in image interpretation and image-guided intervention.

We also have a certain amount of technical knowledge, including a variable understanding of the scientific basis of the techniques which we use in daily practice. As well as that, we possess life skills such as how to balance conflicting demands on our time, how to preserve our sanity in a pressurized environment, and an understanding of the many different meanings of the word “urgent.”

Dr. Giles Maskell.Dr. Giles Maskell.

So here are five things that I’ve learned during my career as a radiologist that others seem to struggle to comprehend:

1. The most expensive test is not always best

Have you noticed how the faith which our clinical colleagues place in the result of an imaging test seems to be directly correlated with its cost? The newest and most expensive test simply has to be better, right? Ultrasound -- cheap and readily available -- don't believe it. PET-CT with a novel tracer -- expensive and hard to get -- it's got to be right. We know that the tests that we've been using for decades can answer most of the important questions and the reason why the novel test seems so good is that we haven't yet had time to work out its limitations. No one else seems able to grasp this.

2. Normal is a slippery word

Think of the last 10 normal chest x-rays you reported and line them up next to each other in your imagination. How similar do they look? Wildly different, I would suspect, depending on the ages, sizes, and shapes of the patients. There is no one version of "normal" when it comes to the chest x-ray. In fact, what we are describing as "normal" is probably defined better by the absence of abnormality, or at least the absence of an abnormality that we consider worth mentioning. With more complex imaging, the extent of variation in appearances between individuals becomes even greater and it becomes ever harder to call something normal. Sometimes we fall back on "within normal limits" (whatever they are). Other times, as Elton John might have sung, "normal seems to be the hardest word."

3. Availability of previous studies is absolutely critical

Most people can understand that when reporting a CT examination, it is helpful to be able to review previous CTs. What they don't appreciate is that review of previous MRI, radionuclide studies, and yes, even plain radiographs, can also change the interpretation. Nor do they understand that often our best chance of obtaining any reliable clinical information about the patient is to find it in our own imaging records.

4. Some diagnoses can only be made in retrospect

Hindsight is a wonderful thing. Once an abnormality has been pointed out to us on an image, it becomes obvious, and we can never "un-see" it. It becomes hard to understand how we or anyone else could ever have failed to see it. We radiologists understand this better than most people because it is part of our daily experience. What nobody else understands is that the ability to identify an abnormality in retrospect -- when the results of subsequent imaging are available -- does not mean that it could or should have been identified at the time of reporting. Knowing, for example, that the patient later presented with a tumor at the splenic flexure of the colon, I can say now that the small filling defect amongst the residue at that site on the CT scan from two years ago probably represented a polyp, but I could not have made that call at the time. You know that this is true, but good luck explaining it to anyone else!

5. Radiology is very difficult

It always seems a bit unfair that the interpretation of histopathology slides is accepted as something only to be undertaken by a specialist whose opinion is accepted without question as the Truth, whereas pretty much anyone will have a go at interpreting a radiographic image. For some reason, the rest of the world thinks it's easy. The fact is that radiology is very difficult, even for very good radiologists. But you knew that, didn't you?

Dr. Giles Maskell is a consultant radiologist at Royal Cornwall Hospitals National Health Service (NHS) Trust, Truro, U.K. He is a former president of the U.K. Royal College of Radiologists. Competing interests: None declared.

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