“My dear, here we must run as fast as we can, just to stay in place. And if you wish to go anywhere you must run twice as fast as that.”

—Lewis Carroll, Alice in Wonderland

One of the many things about radiology that I have found impactful— impactful? Is that a word? Hmmm, guess so. It’s in the dictionary —is the concept of a temporal element of pathology. Things change over time, or may change over time, or don’t change at all over time. We know that how things change (or don’t change) over time can help clue us in to their significance. And, we know, a lot of things are either not going to change or will change slowly. You see a thing, you know it is likely an entity that doesn’t change much, likely not an operable lesion, and you dictate that it is what it is, and that follow-up isn’t necessary unless something else changes. Like clinical findings. We do it all the time. And … you know where I’m going. It gets followed up like a hawk . Monthly MR studies. Biweekly US examinations. Repeat chest film ad infinitum. I think I could save the system a fair amount of money if I was allowed to control when the follow-up studies for some things were performed. A follow-up for a bone island in 3 months? Yep; I’ve seen it. And, lo and behold, it didn’t change. And it didn’t on the next 3-month follow-up. No more follow-up studies on that one (perhaps the patient found a new doctor).

There is another element of this follow-up thing that can occasionally make me pound my head on a table. You’re worried about something. You ask for a follow-up. You are persuasive. And they even put in their note “follow up for change; we will see them back when this is repeated.” They did what you recommended, and you see the repeat. It grew. It changed. And … they do nothing. Order another follow-up. New note in the system: “Follow up for more change; we will see them back when this is repeated.” Jeez.

The last minor point in this is that some things that are still a nothing may change. They are still likely a nothing; they just are a nothing that changed. The occasional smirk I get when I see a colleague who tells me about the nothing that I picked up and recommended nothing on (and they followed up, because, see paragraph 1) and changed a little on the follow-up is a little disconcerting, but I have seen enough now that I don’t let it bother me. I even look at the study for them. “Yes, it changed a little. And is still nothing.”

An important concept an early radiology mentor of mine drove home to me is the following: “We don’t drive the trucks, we just load them.” Time to load some more trucks.

Keep doing that good work. Mahalo.