Imagine this hypothetical scenario.
You’ve got a headache. Sure, everyone gets headaches, but this one is different, and it’s got you worried. You call your doctor, who sends you to the emergency room (the “ER”). The ER doctor who sees you orders a CT, or “cat” scan, of the head. You’re transported to the medical imaging department (“Radiology”) where the scan is performed, and then you’re taken back to the ER.
Do you know what just happened, and what happens next, behind the scenes?
Probably not, unless you’re well-acquainted with the healthcare system and that particular hospital. Do you have any control over this process?
Almost certainly not. You’re in the patient role now, regardless of your background, and the process has taken a life and momentum of its own. You are, in many ways, now just along for the ride, like a floating leaf being whisked down a river. Do you know what questions to ask, or what requests to make to ensure your care is appropriate and your CT scan is read accurately?
Again, almost certainly not. You must trust the process to work correctly because you really don’t have a choice – nor are you truly in control.
After some time passes, the ER doctor walks in, stands at the foot of your bed, and brightly tells you the good news: your CT scan is normal! You can rest easy. The visions you’d been having of all sorts of bad news begin to lift and you count your blessings. Sure, the whole episode was scary and inconvenient and expensive, and you still have a pretty nasty headache, but you’re very relieved and you send a couple of texts to reassure your worried friends and family.
Then, a few months later, you have another bad headache. You debate whether to worry about it much, but it doesn’t go away, so you again go to the ER. It all seems familiar at first…until the ER doctor walks in after your second CT scan and does not have the same bounce in her step that she did last time. Your concern grows a bit when she pulls up a chair next to your bed and sits down to talk to you.
The news this time is not good: there is an abnormality of your brain that is now seen on your cat scan. They’re not sure what it is, but they’re going to do an MRI as soon as they can get you onto the schedule to learn more about it.
Your mind goes down a rabbit hole. What could it be? How serious is it? Whom can you ask for help understanding what is going on?
Fast forward, and the MRI results are in: the lesion is concerning, and by the way, it was subtle but present on your first CT scan. You’re being referred to a neurosurgeon and an oncologist and a neurologist.
Understandably, the deepening concern is now near-panic. How could the first cat scan have been normal when this thing was already visible?
What in the world do you do next? Where do you turn? Whom do you trust? Is the hospital going to give you an honest answer about this thing going forward since they missed it the first time? Can you trust them to accurately evaluate it from now on? Can you trust their diagnosis and treatment recommendations? Do you want them operating on your brain?
The neurosurgeon suggests watching and re-scanning the lesion over time, because it’s unclear what it is and it hasn’t changed since the first CT scan. You are in for months to years of worry, and who knows what the outcome will be. You struggle to explain what’s going on to your loved ones. You struggle to plan your life, vacations, and large events, with this uncertainty hanging over you.
Over the next months to years, your follow-up imaging scans are interpreted a bit differently from each other – sometimes the lesion is reported to be a bit larger or smaller, sometimes it’s better seen or not as well seen as on the most recent prior exam. Your neurosurgeon explains these discrepancies away as just being due to different radiologists’ interpretations.
You might hear things like:
- “Maybe she didn’t have the other prior exams available when she said that?”
- “Perhaps there was a technical difference in the scans? Maybe the technologist had you positioned differently?”
- “Oh, yeah, Dr. Smith read that one – he’s a general radiologist without subspecialty training in neuro-imaging and happened to be the one who pulled your exam from the reading queue. Well, I’d take his interpretation with a grain of salt – don’t worry about it – let’s see what the next scan shows.”
Wait, what? You’re kidding, right? Your mind races – questions rush to your mind, but the answers are not reassuring.
Doesn’t the radiologist who reads each one of my exams compare it to all other prior exams?
No. Doesn’t the technologist ensure that my head is in exactly the same position for each followup scan, so the comparison of the lesion is as accurate as possible?
No.
If the radiology department employs a radiologist who does have subspecialty expertise in interpreting brain MRI scans, isn’t that the radiologist who should read all my brain MRI’s?
Yes, but in reality that’s not how it usually works. Your presumption is accurate and makes a lot of sense, but surprisingly, most radiology departments and practices do not distribute or assign cases for interpretation based on the credentials and sub-specialty training of their available radiologists.
You mean it’s the luck of the draw?
Effectively, yes, in most cases.
Why would a generalist grab my brain MRI off the stack of cases to be read when there were plenty of general cases to be read, and a subspecialist was available to read my brain MRI?
MRIs generate more income than other studies.
So you’re saying it was to make more money?
Typically, yes.
Wait, who missed this lesion on my first cat scan? Another radiologist without subspecialty training?
Typically, yes.
Okay, stop. Let’s rewind a bit.
Is this nightmare scenario realistic or is it made up?
Unfortunately, it’s very real – and common.
Do you know who interprets your medical imaging exams, and reports their findings?
No – almost always, the answer is no. That’s even true for those of us who are physicians when we are in the role of patients.
Your primary care physician and specialists likely do not have formal training interpreting radiology imaging. Therefore, when they have questions about your medical issues that require medical imaging for further evaluation, they will refer you to an imaging center or the radiology department of a hospital to undergo that imaging.
When you have a medical imaging exam performed, like an MRI of the brain, the images of your brain will be interpreted by someone affiliated with that imaging center or radiology department, and an official report will be generated.
This report then becomes a permanent part of your medical record, and your doctor and other specialists will likely rely on its accuracy to explain to you what the imaging showed, and to make further diagnostic and treatment decisions for you.
Can I talk to a radiologist?
In an ideal world, every patient would be able to speak directly with their radiologist. But unfortunately, the realities of time constraints, productivity pressures, and hospital structures make this a rare occurrence. This, in addition to lack of availability of – let alone access to – an appropriate sub-specialist radiologist, is often why patients seek second opinions in radiology.
Here’s what every patient deserves to know.
More often than not, subspecialty radiology cases are not read by subspecialty trained radiologists. This is not advertised to the public, but it’s the truth. When I’ve told friends and family about this, they’ve been not just dismayed and surprised – they’ve been shocked. The assumption among the public is that, when a patient goes to a hospital for medical imaging, the most qualified radiologist will be assigned to read their imaging scan.
But that is not how it works. This problem is not unique to radiology – not at all – but I am a subspecialist radiologist who, after decades in healthcare, believes that this approach, though very common, is quite clearly not in the best interest of quality patient care.
So, I decided to do something about it. I founded MD For Patients to improve patient care by providing thorough and accurate consultations and second opinions. My hope is that patients never have to second guess whether or not a qualified physician is interpreting their images – or whether or not that physician has compared their most recent exam to all of their available, relevant past medical imaging.
So, what’s an important first step towards better healthcare? Providing this kind of information and improved level of service to patients – so that they can make better informed decisions about their treatment.
Stay tuned for more Mythbusting.
