Bigger, smaller, or same?

By C. Douglas Phillips, MD, FACR, Weill Medical College of Cornell University, New York-Presbyterian Hospital, New York, NY

Dr. Phillips is a Professor of Radiology, Director of Head and Neck Imaging, at Weill Medical College of Cornell University, New York–Presbyterian Hospital, New York, NY. He is a member of the Applied Radiology Editorial Advisory Board.

I think it’s rather cool being a paid observer. Because that’s what we are. We get paid for making observations.You are given an exam, and you look it over, and make a series of observations. If you do it all right, and put it together (kind of like a big puzzle), you have a positive effect on patient care. Maybe you even figure out the whole thing. In those cases, you are the HERO. And, you get to relate that story for the rest of your natural life, and bore the crap out of those around you, all of whom have probably heard it 1,000times before.

But, that rarely happens. Usually, your observations are just that—observations. However, they can become distractions. Let’s talk about those—the incidental findings.

Some people get bogged down in the incidental findings, and the report and the referring doc pay that price. What they really wanted to know is one thing, and they can’t find it in your report.

“Hey, is that subdural any different?” And, what they read is a catalog of other observations, none of which they care about. Radiologists see a lot, by and large. Certainly, as we all know, some more than others. Here’s my new rule—if the exam pertains to a finding that is being followed, the first line of the report, and the first line of the impression is this; The known thing is BIGGER, SMALLER, or SAME.

I’m trying to get the residents to do this. Not easy. We all remember that excitement we had as a first- or second-year resident, making an observation (regardless of how small or large, insignificant or not) that someone AGREED with us on. Subsequently, for these folks the incidental finding always—ALWAYS—goes first in the impression.

You’ve seen these reports, or potentially generated them:

  1. Empty sella
  2. Pneumatized crista galli
  3. Huge epidural hemorrhage

Ha! I’d like to declare a moratorium on incidental findings. First to go, the anatomic oddities. That’s right. I just don’t care. BIGGER, SMALLER, or SAME. Stick with the pertinents. I’d allow the anatomic oddities to occupy the final line of any report that made it to at least 2 pages. I had a clinician-friend tell me that they had a term for patients who were worked up incessantly for some incidental finding, almost invariably with negative results. They called them a “vomit”—a “Victim Of Medical Imaging Technology.” Indeed. And, with our radiation-conscious minds all now occupied with minimizing unnecessary exposure, this is a thing we should all work to eliminate. Save the health-care dollars.

So, you have your marching orders. BIGGER, SMALLER, or SAME. Except if you’re talking about an empty sella. Mahalo.

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Bigger, smaller, or same?.  Appl Radiol. 

May 26, 2011

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