A radiologist reflects on indeterminate findings

A radiologist reflects on indeterminate findings

Radiologists care about their patients, even though most diagnostic radiologists don’t meet and greet their patients the same way direct-care clinicians do.

Some people have the erroneous perspective that radiologists and pathologists don’t care about the welfare of their patients. It is possible for us to understand that view if we look at radiologists and pathologists as isolated workers who work in dimly lit rooms. But that perspective is woefully short-sighted and anachronistic. For this post, ignore the fact that I see patients daily as an interventional radiologist. We are the “surgeons” within the radiology community and I greatly enjoy the hands-on nature of my sub-specialty.

As a radiologist, I am reminded daily that an interpretation of an imaging study such as a CT scan or an ultrasound could send a patient to surgery or change their life forever with an unexpected diagnosis of cancer. My colleagues and I discuss various studies daily in order to learn from “interesting” interpretations. There are learning points to take away from many studies that pass in front of my eyes each day.

Sometimes, though, we view a study and there are findings which are “indeterminate,” or are otherwise unable to be neatly categorized into “known” entities. This fact is the nature of the beast, unfortunately. We are all human and humans do not always fit neatly into understandable categories. So why should we expect every imaging finding to be clear and understandable?

Also, cancers start from one cell. So, one should be able to readily understand that, until a cancer becomes a certain size, it may be “too small to further categorize.” A surgeon, used to dealing with tangible structures such as a liver, gallbladder or kidney, may not readily accept that a 4 mm vague “splotch” on a chest x-ray is not able to be categorized as more than “indeterminate.” In fact, the Fleischner society has published clear and concise recommendations for indeterminate lung nodules.

It is a fundamental truth of life that humans are not categorized into neat little groups. What we try to do, as radiologists and as physicians, is make definitive diagnoses where possible, dismiss benign, irrelevant findings whenever possible, and offer helpful suggestions about the remaining “indeterminate” findings. Understanding that radiologists and pathologists attempt to restore order to that chaos may help you understand what we radiologists wrestle with when findings are indeterminate.

Paul Dorio is an interventional radiologist who blogs at his self-titled site, Paul J Dorio, MD.

Image credit: Shutterstock.com

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  • http://twitter.com/PICUMD Mohamed Gaffoor

    I feel the best way to deal with “indeterminate” findings is to have a face to face conversation with the radiologist while both of you look at the monitor and review the films. I find when I tell the radiologist what i’m looking for it helps them interpret the study and then helps me care for the patient. While logistically arranging this type of meeting can be challenging it almost always yields useful information.

    • ninguem

      You mean…..clinical correlation is suggested?

    • http://drpauldorio.com Paul Dorio

      More physicians/colleagues should do the same. Thanks very much for the input!

  • Guest

    The radiologist makes more in 5 minutes reading the scan than the ordering docs makes in the 45 makes it takes to evaluate a patients abdominal pain with a H&P, discuss the “indeterminate findings”, answer questions and write up a disposition.

    • http://drpauldorio.com Paul Dorio

      Your inaccurate and anachronistic comment is inflammatory and insulting, not to mention it puts you in a poor light. Many radiologists now make less than $30/CT scan while a 45 minute consult reimburses around $100. You might consult a knowledgeable billing assistant/company to improve your mud-slinging effectiveness.

  • http://twitter.com/TFontyn Trish Fontyn

    MD’s may at times press for greater certainty to support treatment decisions but please bear in mind that in a legal proceeding, your interpretation of indeterminate data can have far-reaching and unanticipated consequences. There is no specialty whose words carry greater legal weight.

    • http://drpauldorio.com Paul Dorio

      Nothing is more apparent to a radiologist. Thanks for your comments.

  • Rob Burnside

    We’d all like to be right 100% of the time, but no one is. And let’s not forget that errors can occasionally have good consequences. After a biopsy revealed prostate cancer, I was sent for a bone scan which was misread. The radiologist saw metastasis in my spine and I was then given a CT scan which, to my great relief, showed no PC spinal metastasis but did reveal a previously unknown (and rather large) iliac aneurysm, since corrected. I’m convinced this error saved my life. Would I have received the CT scan if the radiologist had reported indeterminate spinal findings? Maybe not. Still, there’s certainly a place for “indeterminate” but I think most patients would prefer it be accompanied by a best guess.

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