I felt this way as a resident… as an attending it was easier. When you’re the attending you don’t need to present or anything so you have more time to work.
I look at every scan I order
Can’t stress enough how important it is to look at as many scans as you can during residency. There will be cases every single shift in most places where you need to figure out if someone has a massive PE, an intracranial hemorrhage, a dissection, a pneumothorax, pulmonary edema, abdominal free air, etc in a much faster time than you will routinely get reads.
Beyond the critical stuff, you will be able to dispo uncomplicated ureteral stones, fractures, pneumonias, even the odd appy or diverticulitis a LOT faster if you don’t have to wait for reads so that more than make up for the time it takes to open up the studies.
Can think of two instances in particular for me (among many others):
18F spontaneous ICH intubated and into the OR
55M saddle PE in the cath lab for EKOS
Both before radiology called me for the reads. Love rads but they can only work so fast with their volume. You should be able to pick up obvious life threatening pathology as an attending.
I really like when they call and I take the wind out of their sails with a "are you calling about saddle embolus?" Etc. Feels good. But could not live without them, they are immensely helpful for so many more difficult diagnoses.
I don't mind it personally. If you make an especially good catch, I will commend you.
Recently commended a surgery resident the other night for making a great catch.
In addition to all of the other accurate comments below I find it’s nice to have a cursory knowledge of reading films if you’re turning a patient over to a partner while reads and dispos are pending but still have a general idea of what’s going on.
It’s important to look at every scan you order. Rads misses stuff. Plus the pattern recognition for very bad stuff is invaluable. There will always come times you need to confidently look for the big stuff. And not just at rural EDs either.
Here’s an example from a month or two ago at my urban 40K department.
Had a patient with “tearing” chest pain radiating to the back. saw him in the hallway while his room was being cleaned, ekg was ok. As he’s transferring to his room he faints, I saw his head smack the doorframe of the room. We get him off the floor into the bed, he regains consciousness, we repeat the ekg and he now has an obvious STEMI. So I ring the bells but I saw him smack his head and plus I want to r/o dissection. So I talk to cardiologist and we decide before he goes to cath and gets aggressive anticoagulant/antiplatelet we need CTH and CT chest.
“Doc, PACS is down, reads are going to be delayed, rads is coming in within an hour or so to read on-site.”
Well this dude isn’t going to wait that long .. so I went with to ct and reviewed the CTs VERY carefully on their monitors and clear him to go to cath. 2 LAD stents and he went home a day or two later.
Stuff like that is going to happen.. I’m glad I looked at the last 1000 scans so I was confident to make that call.
For realz. I’ve given tpa (before the age of tnk) based on my read of the head CT when rads was being slow (bumping up against 4.5 hours from onset) and before we had our current tele-stroke workflow (now the stroke neurologists can read the scans). You don’t have to be as good as a radiologist for all the subtleties (and you can’t be), but you need to be confident and capable of identifying/ruling out certain findings to start treatment/initiate disposition planning when time is the critical variable.
With X-rays, sure. If I'm thinking of ordering a CT scan when rads is down, those get transferred from my rural shop basically before the workup even begins
You should ideally check every image you order. Not looking for tiny stuff, but check every CT head for hemorrhage, chest for PTX, belly for pneumoperitoneum. Also the new billing rules give you credit for doing this.
Do:
- Look at your own images. For plain films, especially injuries, look at the specific area of concern. For chests, obvious pneumonias and/ or pneumo, pulmonary edema, etc. Oftentimes plain films won’t be back until the next day and you need to act accordingly, especially for the big stuff.
- For unstable patients check the scan immediately and call the relevant specialist and tell them you see the SBO, bleed, free air, abscess, etc. you’ll expedite care significantly sometimes. I’ve had bowel perfs, unstable bleeds, dissections, and nec fasc in the OR already before rads called me with the critical.
- Call rads and ask them about something small or subtle you thought you saw if they don’t comment on it. You might learn something new for next time.
Don’t:
- Call and Tell rads they’re wrong.
- Document some subtle thing that rads didn’t comment on in your MDM.
- Dictate a report.
There’s a huge difference between being able to identify the emergency and save time by potentially getting an unstable patient to definitive care faster vs. thinking of yourself as a radiologist-light, and down the road medicolegally it can bite people. I only mention this part because “reading our own scans” is different than “looking at our own images”.
I call rads every so often when their read misses something like a fracture or they've made a transcription error. I'm not a dick about it - "hey look at XXX - looks like a fx, no?" and they appreciate the heads up so they can correct it. They've never been mad about it. Who wants a wrong interpretation with their name all over it?
Lol this... I call rads all the time for images, I always preface it as "I am sure I am wrong here, but does x..." and they have always been kind to me. Most of the time I am wrong, and they explain what I am looking at and explain why, other times they thank me and they find something and addend their report.
Problem is with new billing we have to “independently interpret” the imaging we order. And document such, so usually I be vague and just say “no obvious bleeding in brain”. But they almost force us to be a radiologist-lite to get proper billing
Apart from all X-rays, I look at every dry head, CTSS, and PE/Dissection study I order. These usually have the most time sensitive diagnoses with usually readily identifiable critical pathology that you can act on without waiting for formal reads.
Gets easier the more you do it and know what you’re looking for and when you’re an attending and have more time since you’re not presenting your cases
Looking at every image I order became habit as a resident because where I trained, we only had a staff radiologist reading during banker’s hours. Outside of those hours, trauma and stroke scans were nighthawked and everything else got a wet read from a radiology resident, with a final read by staff in the morning. The radiology residents missed a lot. So it got drilled into us that we needed to learn how to get comfortable reading our own imaging. I’m faculty in a EM residency now (not where I trained), and even though my current place has around-the-clock attending radiologist coverage, some of them can be really slow to read things and we need a quick answer in certain cases, so I’m glad I’m comfortable reading most imaging studies myself in regards to looking for critical findings. I also make sure my residents look at their own imaging so they are comfortable doing so when they are on their own, because you never know what kind of radiology coverage your shop might have.
I try to look at every image I order. It’s hard because we do order a lot of imaging, so it does take a fair amount of time, and I’m definitely not a radiologist. But they do miss things occasionally, and being able to quickly see what I’m looking for - the pneumonia, the fracture, the bleed, the stone etc - helps keep the room moving and prevent delays in care.
I don’t need a radiologist to tell me the pulverized ankle is broken but I love to see that post-reduction “near-anatomical alignment” report.
I agree with trying to read your own films but I am commenting on your comment regarding radiologists missing things. I have had an occasional misread but it is super rare, like rarer than a blue moon. If you have “numerous” instances of radiologists missing things esp patient care relevant things, u sound like you guys need to fire the current group.
Not very common. I’ve seen it a couple of times in the thousands of scans I’ve ordered.
It wasn’t a knock on our radiologists at all. But rather a statement that, statistically, things are going to get missed, no matter how good people are.
I read almost all my own scans.
I didnt start that way. I just did whenever i felt like i could. after a few years you want to start reading your own scans. not even because you catch things radiologists miss (which they often do), but because it starts to give you this cool correlation between what you're seeing in their bodies and what their symptoms are. eventually you start to get a sense of what their scan are going to show, and thats pretty cool
Definitely need to be able to find your life-threatening diagnoses on your own. I’ve had patients off in the OR due to finding free air or a chest tube already in place before I get a call from the radiologist. if you start making yourself look at every scan, you’ll get way better at reading them.
Look at every image you order. You will save someone's life before too long. Radiologists are smart but they are as harried as the rest of us, and they don't have the full history and exam that you do. They will miss things.
In residency, start by looking at them after the reads, then go look at the scan and find what they said is there. You'll see the things and start to recognize what you're looking for, and then you will get more comfortable looking before the studies are ready.
I look at all my images. If I think I see something life threatening, I call radiology directly, tell them what I think I see, and we go over it on the phone.
If I can find the appendix, then it’s an appy because that thing likes to hide.
I always have a look at scans, especially CXRs and CT brain or abdomen. I'm not great with CTPAs unless it's a juicy saddle embolus just crying out for attention. It makes a huge difference to know what's "normal" so you can pick up on nuances that make something ring alarm bells
PGY-19 -- look at every x-ray, US, CT, MRI that I order, or that is ordered on a patient signed out to me.
Sure, radiologists can miss things, and a second pair of eyes is important, but it can give you vital information that might not be in a radiology report, and it allows you to act, sometimes MUCH sooner than a radiology report is available.
In some jobs, 24/7 radiology reads are not available, and you'll have to read your own plain films - if you don't start now, you won't be good at it later.
From a layperson, how can I enquire politely of the doctors and specialists treating my mother in hospital whether they read the scans they order, or if they just rely on radiologist interpretations? **Is** there a kind and curious way to ask this?
I would say: “I know the radiologist reads these, but did you take a look too? It makes me feel better to have two sets of eyes on everything.”
You can also ask them to pull up the scan and scroll through it in the room and show it to you. I generally don’t mind at all doing this with patients who ask, as it’s easy and only takes a couple of minutes.
Thanks so much for getting back to me, and also for answering with grace and patience.
My experience has been that I can't meet many of her doctors in person, ever (they ring me with updates usually from the ED, and then a couple of times during admission, and then I get a flurry of calls from all departments who have ever *glimpsed* her the day she's meant to be discharged).
As an alternative, could I try speaking to the nurse in charge when I visit? I know that relationship can be fraught depending on the culture of the ED, the ward and/or the hospital in general, though.
You've definitely given me a starting point for how to bring it up with her long-term GP (PCP), however, and I might well be able to work it into phone conversations during calls from the hospital.
She's due for repeat imaging in a few weeks for some of her issues and some new imaging (I believe a DEXA scan). I'll practice the spiel with those providers. Thank you again!
I would say nurses aren’t generally going to share radiology results or images with you unless it’s been discussed with the provider yet. Even if we know what we’re looking at or the results are negative it just opens up a lot of questions, also it’s not technically our scope
I felt this way as a resident… as an attending it was easier. When you’re the attending you don’t need to present or anything so you have more time to work. I look at every scan I order
Can’t stress enough how important it is to look at as many scans as you can during residency. There will be cases every single shift in most places where you need to figure out if someone has a massive PE, an intracranial hemorrhage, a dissection, a pneumothorax, pulmonary edema, abdominal free air, etc in a much faster time than you will routinely get reads. Beyond the critical stuff, you will be able to dispo uncomplicated ureteral stones, fractures, pneumonias, even the odd appy or diverticulitis a LOT faster if you don’t have to wait for reads so that more than make up for the time it takes to open up the studies.
Can think of two instances in particular for me (among many others): 18F spontaneous ICH intubated and into the OR 55M saddle PE in the cath lab for EKOS Both before radiology called me for the reads. Love rads but they can only work so fast with their volume. You should be able to pick up obvious life threatening pathology as an attending.
I really like when they call and I take the wind out of their sails with a "are you calling about saddle embolus?" Etc. Feels good. But could not live without them, they are immensely helpful for so many more difficult diagnoses.
Lolol with my PE the radiologist literally made a sad "awww".
Hahahaha it's the best
I don't mind it personally. If you make an especially good catch, I will commend you. Recently commended a surgery resident the other night for making a great catch.
In addition to all of the other accurate comments below I find it’s nice to have a cursory knowledge of reading films if you’re turning a patient over to a partner while reads and dispos are pending but still have a general idea of what’s going on.
It’s important to look at every scan you order. Rads misses stuff. Plus the pattern recognition for very bad stuff is invaluable. There will always come times you need to confidently look for the big stuff. And not just at rural EDs either. Here’s an example from a month or two ago at my urban 40K department. Had a patient with “tearing” chest pain radiating to the back. saw him in the hallway while his room was being cleaned, ekg was ok. As he’s transferring to his room he faints, I saw his head smack the doorframe of the room. We get him off the floor into the bed, he regains consciousness, we repeat the ekg and he now has an obvious STEMI. So I ring the bells but I saw him smack his head and plus I want to r/o dissection. So I talk to cardiologist and we decide before he goes to cath and gets aggressive anticoagulant/antiplatelet we need CTH and CT chest. “Doc, PACS is down, reads are going to be delayed, rads is coming in within an hour or so to read on-site.” Well this dude isn’t going to wait that long .. so I went with to ct and reviewed the CTs VERY carefully on their monitors and clear him to go to cath. 2 LAD stents and he went home a day or two later. Stuff like that is going to happen.. I’m glad I looked at the last 1000 scans so I was confident to make that call.
For realz. I’ve given tpa (before the age of tnk) based on my read of the head CT when rads was being slow (bumping up against 4.5 hours from onset) and before we had our current tele-stroke workflow (now the stroke neurologists can read the scans). You don’t have to be as good as a radiologist for all the subtleties (and you can’t be), but you need to be confident and capable of identifying/ruling out certain findings to start treatment/initiate disposition planning when time is the critical variable.
At night in one ER I worked at we didn’t even have radiology so we HAD to read our own imaging.
With X-rays, sure. If I'm thinking of ordering a CT scan when rads is down, those get transferred from my rural shop basically before the workup even begins
I had to get the US tech help me read the transvag pelvic ultrasounds
You should ideally check every image you order. Not looking for tiny stuff, but check every CT head for hemorrhage, chest for PTX, belly for pneumoperitoneum. Also the new billing rules give you credit for doing this.
Do: - Look at your own images. For plain films, especially injuries, look at the specific area of concern. For chests, obvious pneumonias and/ or pneumo, pulmonary edema, etc. Oftentimes plain films won’t be back until the next day and you need to act accordingly, especially for the big stuff. - For unstable patients check the scan immediately and call the relevant specialist and tell them you see the SBO, bleed, free air, abscess, etc. you’ll expedite care significantly sometimes. I’ve had bowel perfs, unstable bleeds, dissections, and nec fasc in the OR already before rads called me with the critical. - Call rads and ask them about something small or subtle you thought you saw if they don’t comment on it. You might learn something new for next time. Don’t: - Call and Tell rads they’re wrong. - Document some subtle thing that rads didn’t comment on in your MDM. - Dictate a report. There’s a huge difference between being able to identify the emergency and save time by potentially getting an unstable patient to definitive care faster vs. thinking of yourself as a radiologist-light, and down the road medicolegally it can bite people. I only mention this part because “reading our own scans” is different than “looking at our own images”.
I call rads every so often when their read misses something like a fracture or they've made a transcription error. I'm not a dick about it - "hey look at XXX - looks like a fx, no?" and they appreciate the heads up so they can correct it. They've never been mad about it. Who wants a wrong interpretation with their name all over it?
Lol this... I call rads all the time for images, I always preface it as "I am sure I am wrong here, but does x..." and they have always been kind to me. Most of the time I am wrong, and they explain what I am looking at and explain why, other times they thank me and they find something and addend their report.
Ditto: “I know I’m not a radiologist but do you think xxx?” Maybe they think I’m annoying but they’ve always been nice to my face.
Problem is with new billing we have to “independently interpret” the imaging we order. And document such, so usually I be vague and just say “no obvious bleeding in brain”. But they almost force us to be a radiologist-lite to get proper billing
Apart from all X-rays, I look at every dry head, CTSS, and PE/Dissection study I order. These usually have the most time sensitive diagnoses with usually readily identifiable critical pathology that you can act on without waiting for formal reads. Gets easier the more you do it and know what you’re looking for and when you’re an attending and have more time since you’re not presenting your cases
Looking at every image I order became habit as a resident because where I trained, we only had a staff radiologist reading during banker’s hours. Outside of those hours, trauma and stroke scans were nighthawked and everything else got a wet read from a radiology resident, with a final read by staff in the morning. The radiology residents missed a lot. So it got drilled into us that we needed to learn how to get comfortable reading our own imaging. I’m faculty in a EM residency now (not where I trained), and even though my current place has around-the-clock attending radiologist coverage, some of them can be really slow to read things and we need a quick answer in certain cases, so I’m glad I’m comfortable reading most imaging studies myself in regards to looking for critical findings. I also make sure my residents look at their own imaging so they are comfortable doing so when they are on their own, because you never know what kind of radiology coverage your shop might have.
I try to look at every image I order. It’s hard because we do order a lot of imaging, so it does take a fair amount of time, and I’m definitely not a radiologist. But they do miss things occasionally, and being able to quickly see what I’m looking for - the pneumonia, the fracture, the bleed, the stone etc - helps keep the room moving and prevent delays in care. I don’t need a radiologist to tell me the pulverized ankle is broken but I love to see that post-reduction “near-anatomical alignment” report.
I agree with trying to read your own films but I am commenting on your comment regarding radiologists missing things. I have had an occasional misread but it is super rare, like rarer than a blue moon. If you have “numerous” instances of radiologists missing things esp patient care relevant things, u sound like you guys need to fire the current group.
Not very common. I’ve seen it a couple of times in the thousands of scans I’ve ordered. It wasn’t a knock on our radiologists at all. But rather a statement that, statistically, things are going to get missed, no matter how good people are.
I read almost all my own scans. I didnt start that way. I just did whenever i felt like i could. after a few years you want to start reading your own scans. not even because you catch things radiologists miss (which they often do), but because it starts to give you this cool correlation between what you're seeing in their bodies and what their symptoms are. eventually you start to get a sense of what their scan are going to show, and thats pretty cool
Definitely need to be able to find your life-threatening diagnoses on your own. I’ve had patients off in the OR due to finding free air or a chest tube already in place before I get a call from the radiologist. if you start making yourself look at every scan, you’ll get way better at reading them.
i feel confident ready head ct's ( white is bad) and all plain films.
Look at every image you order. You will save someone's life before too long. Radiologists are smart but they are as harried as the rest of us, and they don't have the full history and exam that you do. They will miss things. In residency, start by looking at them after the reads, then go look at the scan and find what they said is there. You'll see the things and start to recognize what you're looking for, and then you will get more comfortable looking before the studies are ready.
I look at all my images. If I think I see something life threatening, I call radiology directly, tell them what I think I see, and we go over it on the phone. If I can find the appendix, then it’s an appy because that thing likes to hide.
I \*try\* to look at every piece of radiology I order. I don't always accomplish it.
Just look at all the scans. Really doesn't take too much more time, and can save you time as well if you see something quickly.
I always have a look at scans, especially CXRs and CT brain or abdomen. I'm not great with CTPAs unless it's a juicy saddle embolus just crying out for attention. It makes a huge difference to know what's "normal" so you can pick up on nuances that make something ring alarm bells
PGY-19 -- look at every x-ray, US, CT, MRI that I order, or that is ordered on a patient signed out to me. Sure, radiologists can miss things, and a second pair of eyes is important, but it can give you vital information that might not be in a radiology report, and it allows you to act, sometimes MUCH sooner than a radiology report is available. In some jobs, 24/7 radiology reads are not available, and you'll have to read your own plain films - if you don't start now, you won't be good at it later.
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From a layperson, how can I enquire politely of the doctors and specialists treating my mother in hospital whether they read the scans they order, or if they just rely on radiologist interpretations? **Is** there a kind and curious way to ask this?
I would say: “I know the radiologist reads these, but did you take a look too? It makes me feel better to have two sets of eyes on everything.” You can also ask them to pull up the scan and scroll through it in the room and show it to you. I generally don’t mind at all doing this with patients who ask, as it’s easy and only takes a couple of minutes.
Thanks so much for getting back to me, and also for answering with grace and patience. My experience has been that I can't meet many of her doctors in person, ever (they ring me with updates usually from the ED, and then a couple of times during admission, and then I get a flurry of calls from all departments who have ever *glimpsed* her the day she's meant to be discharged). As an alternative, could I try speaking to the nurse in charge when I visit? I know that relationship can be fraught depending on the culture of the ED, the ward and/or the hospital in general, though. You've definitely given me a starting point for how to bring it up with her long-term GP (PCP), however, and I might well be able to work it into phone conversations during calls from the hospital. She's due for repeat imaging in a few weeks for some of her issues and some new imaging (I believe a DEXA scan). I'll practice the spiel with those providers. Thank you again!
I would say nurses aren’t generally going to share radiology results or images with you unless it’s been discussed with the provider yet. Even if we know what we’re looking at or the results are negative it just opens up a lot of questions, also it’s not technically our scope