“It is one of the blessings of old friends that you can afford to be stupid with them.”
—Ralph Waldo Emerson
Indeed. Ralph was correct. I am pretty fortunate to have a lot of old friends who I am pretty much invariably stupid with. And, they feel free to be stupid with me. I prefer it that way. So, recently one of my old friends shared with me a resident-concocted ULTIMATE hedge. I have minimally modified it and am providing it for your entertainment, thoughtful reflection, potential medicolegal assistance, or maybe just for my own chuckles. We have discussed the art of the hedge before, and I think you know where I stand on this. Everyone does it. Everyone. Some of us do it much better than others, and some should instruct in the finer points, having plainly mastered them. And, I stand by a prior statement—NO ONE does the hedge better than a pathologist. We radiologists are good. Some of us are experts. But we rise to the brown belt level. Pathologists wear the black belt.
So, here it is. Put this in a report sometime and let me know how it bounces around. I can assure you it will make you a star in your reading room:
“The study is limited by patient body habitus, motion artifact, inability to tolerate positioning, artifact from external and internal hardware, low-dose technique, lack of intravenous, oral, rectal or intrathecal contrast, and equipment malfunction. Within these limitations, there are no gross findings to definitely suggest possible acute abnormality within the submitted images of the visualized portions of the area of clinical interest. However, the possibility of clinically significant pathology not identified on the current study cannot be excluded. As such, further evaluation with contrast enhanced MRI of the brain, sella, face, TMJs, internal auditory canals, temporal bones, neck, cervical, thoracic and lumbar spine, heart, chest, abdomen, pelvis, prostate, thighs, knees, lower legs, ankles, feet, toes, sternum, scapula, shoulders, upper arms, elbows, forearms, hands, and fingers is recommended. Additionally, CT urography, MR defecography, Sniff test, MUGA study, radiographs of the mastoid air cells, skeletal survey, bone age study, ultrasound guided paracentesis or biopsy, fiduciary marker placement, and shuntogram may also be helpful if clinically indicated or for confirmation. Comparison with prior studies may also be useful.”
Kudos to Drs. Krieger and Taragin; hopefully, my additions are acceptable. I can appreciate that cascading complexity, the prose, the rhythmic feel, the all-inclusive nature. Truly wonderful. Use it whenever you feel the need. Like, perhaps right now, with that incredible-looking thing you just noticed on that brachial plexus study. What does that look like, a pumpkin or something? Jeez.
Mahalo.Back To Top
Wet Read: The ultimate hedge. Appl Radiol. 2015;44(11):72.
Dr. Phillips is a Professor of Radiology, Director of Head and Neck Imaging, at Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, NY. He is a member of the Applied Radiology Editorial Advisory Board.