Letters from Maine

See for yourself


About 800 million radiology exams were performed in this country in the past year, and they generated approximately 60 billion images, according to an article published in 2017 in the Wall Street Journal (“No need for radiologists to be negative on AI,” by Greg Ip, Nov. 24, 2017). How many of those millions of radiology studies did you order? And how many of the scores of images you requested did you see with your own two eyes? In fact, how many of the radiologists’ reports that were sent to you did you read in their entirety? How often did you just skip over the radiologist’s CYA disclaimers and simply read the final summary, “exam negative”?

Doctor looking at chest scans XiXinXing/Thinkstock
Can you sense that I’m warming up for a when-I-was-your-age lecture? Good! You won’t be disappointed when I tell you that, when I was a house officer, we were expected to shuffle off to the darkened bowels of the hospital (the radiology department had no need for windows) and take a look at any x-ray we had ordered on our patients. During the day, this exercise was intended to be an educational field trip. But, at night, when the radiologists were sleeping comfortably at home in the suburbs, this trip to the basement was a fact-finding mission in which we were asked to rely on our memory bank of images we had seen during our brief training. Of course, we could call in the radiologist if we felt the patient’s situation was so critical that we needed an official interpretation of the study we had ordered. But often, house officer machismo kept us from reaching for the phone. To some extent, this rule of if-you-order-it-you-look-at-it functioned as a healthy deterrent against frivolous ordering of marginally valuable studies.

I enjoy the challenge of interpreting x-ray images. In fact, I toyed with becoming a pediatric radiologist, but that career path would have meant settling in or near a large city, a compromise my wife and I were unwilling to make. I hoped to continue my habit of looking at all my patients’ x-rays, but because my practice was not in or near the hospital, I reluctantly had to bend my rules and admit I didn’t see every image I had ordered. But, I did read every report in its entirety. In one case, an offhand comment buried in the middle of the radiologist’s report referring to the “residual barium from a previous study” caught my eye, because I knew the patient hadn’t had a previous contrast study. Unfortunately, the neuroblastoma that the radiologist had missed initially, and I had seen the next day, never responded to treatment.

Toward the end of my career, digital imagery allowed me to view my patients’ x-rays without having to leave my desk, which got me closer to my goal of seeing all my patients’ studies. However, the advent of computerized axial tomography and magnetic resonance imaging meant that an increasing number of studies pushed my anatomic knowledge beyond its limits.

I suspect that many of you benefited from the if-you-order-it-look-at-it mantra during your training. How many of you have continued to follow the dictum? With the advent of digitized imagery, there is really little excuse for not taking a minute or 2 to pull up your patients’ images on your desktop. One could argue that looking inside your patient is part of a complete exam. Forcing yourself to take that extra step and look at the study may nudge you into thinking twice about whether you really needed the information the imaging study might add to the diagnostic process. Was your click to order the study just a reflex subliminally related to the fear of a lawsuit? Was it important enough to deserve a firsthand look?

At the very least, being able to say, “I’ve looked at your x-rays myself, and they look fine” may be more comforting to your patient than a third-hand relay of a “negative reading” performed by someone whom they have likely never met.

Dr. William G. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years.

Dr. William G. Wilkoff

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

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