I suppose for most physicians, we write to process a tough interaction, a disheartening conversation, or a terrible day. In truth, I write daily. And most often, it’s to process someone else’s terrible day. That’s the job of a radiologist. To look at a patient’s CT scan or ultrasound or MRI or x-ray, interpret what I see, and write a report. To put in writing that there is a new cancer, or the tumor hasn’t responded to treatment, or the appendix is ruptured.
I can’t even say the writing is good. It’s utilitarian—there’s no time to be creative when thirty more patients’ scans are waiting. There is no mass in the liver. What’s the shorter way to say that? No liver mass is seen. How about this: No liver mass. Here’s the award winner—Liver: Normal. It’s funny how hard it can be to declare something “Normal”. There’s always the fear that you could be missing something small or even undetectable.
Because of this uncertainty, I may find myself writing two hundred words just to say, in the end, nothing to worry about here, move on. My gut says it’s a normal scan. Or else it’s close enough to normal, that to intervene would probably do more harm than good. But on rare occasions, tiny unassuming nodules might grow into dangerous masses, and we can’t always tell how they might behave. As a result, we hedge our bets and spend extra words in case a lawyer comes around one day and says, “Why didn’t you mention this or that?” So it is that I may write day in and day out something wholly routine and unsatisfying. Sure, you could say I’m delivering good news by reporting the study as benign. But then, I wonder: why was this CT or MRI even ordered? My Internal Medicine professor in medical school often reminded us that 90% of diagnoses can be made with history and physical alone. If that was put into practice, I’d probably be out of job since no one would need radiology. So, perhaps I should be appreciative, keep my head down, and just keep writing my reports.
But radiology reports can be tiresome, for reasons existential as well as aesthetic. By convention, a radiology report is a neatly divided combination of fact and opinion. In the first portion, the “Findings,” I describe the facts that I see on the screen, and in the second section, the “Impression”, I offer my professional opinion of what these facts mean. But if you were to read my report, you might not tell one section from the other. This is largely because convention also dictates that, in radiology reports, we write in the passive voice. The convention has been passed down from radiology attending to resident since the beginning, and the result is a semblance that the radiologist’s impressions represent the objective truth. No liver mass is seen. Seen by whom? By me?
It weighs on you, being so distanced from your own opinion. We radiologists are already distanced from our patients, providing unseen care, behind the scenes. By one survey, nearly 80% of patients thought that radiologists were radiographers (the technologist who performs the study). Our report may be the only contact we have with them. Sometimes, when reading a clinic note from the front-line physicians, I’m a little jealous. “I explained to Mrs. A that I do not think she is a surgical candidate.” How freely they throw around personal pronouns, these internists! Or, in an operative report: “Then I retracted the colon, which separated quite nicely.” Quite nicely! How I wish I could write something so artistic and subjective! The liver looks quite nice; I don’t see any mass.
Instead, I usually write something unimaginative—Liver: Normal—or, worse, noncommittal and vague. Tiny density in the liver is too small to characterize but statistically, is likely a benign cyst. Please correlate clinically for history of malignancy. Because everything exists, on the radiologist’s monitor, in uncertain shades of grey.
Sometimes, for reasons I don’t understand, I sneak a bit of myself into the Impression. Take the case of Mr. X, a man in his forties, who got a CT scan from the Emergency Room for abdominal pain. I noticed gas in the bladder and focal wall thickening. Nine times out of ten, gas in the bladder is iatrogenic—meaning, a healthcare provider put it there, often by placing a Foley catheter through the urethra, to drain the urine. But there was no catheter on Mr. X’s scan. As often happens, the catheter might have been placed and removed before the scan. In medical school, we’re taught, “When you hear hoof beats, think horses not zebras.” The most common diagnosis is usually the right one. But in the dark solitude of the reading room, the mind can wander, to adventures in the Serengeti where zebras roam free, and I found myself thinking about a fistula, an abnormal communication between the colon and the bladder. In Mr. X’s case, the colon was unusually close to the top of the bladder, and, come to think of it, the adjacent bladder wall was a little thickened.
So, in my Impression, I wrote, quite boldly: “I believe this could represent one of two scenarios: If the patient recently had a Foley Catheter to explain the gas, then the bladder wall thickening could represent a mass, for which I recommend urology consultation. If the patient didn’t have a Foley, then the thickening could represent a colovesicular fistula related to a remote episode of acute diverticulitis.”
The shorter, more traditional way to write that would have been: “Bladder mass versus colovesicular fistula. Recommend correlation with recent Foley placement.” But with two words, I cast myself as the Gandhi of the radiology suite. I believe.
My small acts of defiance do not go unnoticed by my fellow radiologists. When they read my reports that employ the elusive ‘I’, they come to me and say with a chuckle, “I got a kick out of your Impression!” It was as if I was committing a microaggression against the system just for laughs. Don’t they feel it too? Don’t they know that it’s in service of asserting a sense of belonging!
And my target readership, the physicians who order imaging studies? I don’t know how they feel about my experiments with the first-person. My impression is that they just want one thing—my Impression. Or rather, The Impression.
And yet sometimes, even the Impression is skimmed or ignored.
Two days after I reviewed Mr. X’s scan, I followed up on his hospital course. Sure enough, everyone—the ED physician, the Hospitalist, the Urologist—was focused on his abdominal pain. And no one was impressed by my fistula theory…if they’d read it at all. It seemed they had stopped short at the first part—bladder mass—a non-emergent problem that could wait for a later date, a clinic appointment in a few weeks.
Now, I hesitate to criticize these brave clinicians on the front line who deal directly with the blood, tears, and guts of every patient’s case. They see all the clinical facts that I’m not exposed to. Something may look abnormal on a CT scan, but it could turn out to be a complete fake out if the patient is laughing and eating and is the picture of good health.
And yet, I know there can be an advantage in my radiologist’s remove. One step away, I see only the evidence on the screen. It’s almost more intimate, seeing through a person’s skin to their insides. It enables me to see the facts for what they are, and not be biased by the rest. And when it came to Mr. X, things weren’t adding up. The medicine team’s work up seemed to be going in a completely different direction.
So on a whim, feeling a bit like a meddling neighbor, I called the medicine attending, and I made the case for a fistula.
“I read the ED physician’s note, and he mentioned in passing that the patient had noticed brown urine. Why don’t you send the patient back to me and I’ll do a CT with rectal contrast, to check for a fistula and put the issue to rest.”
She admitted that her team had been stumped on his case, was thankful for the input, and would send him right away.
I felt a sense of validation. Finally, my voice would be heard.
My resident, on the other hand, felt differently. He realized that I had just volunteered him for the job of placing the rectal tube through which we would instill the contrast. No one likes receiving a rectal tube, and no healthcare provider likes putting one in.
“Don’t worry,” I said, “We’ll do it as a team.” If we were doing this all based on my hunch, I was resolved to be there.
Within the hour, Mr. X was in our department, on the CT scanner. That he was in pain was clear. Our CT technologists had asked him to remove his underwear so we could place the rectal tube. They were on the floor, visibly soiled. Something was clearly awry.
After introducing myself and explaining what we were about to do, I thought of also letting him know that I read his initial CT scan, and that I put together the clues that would hopefully give us the answer to his pain. Here, I could assert my sense of belonging in his care. But, in face of his writhing discomfort, I decided against it, seeking instead to get the procedure done as quickly as possible. Besides, I didn’t exactly want him to associate radiologist with the jerk who gave me a rectal tube while I was in a lot of pain for the rest of his life.
We placed the tube. It wasn’t pleasant. We instilled the contrast. It was even less pleasant. We performed the CT scan. Then we parted, Mr. X to the brightly lit patient ward, and my resident and I to our dark reading room. There, in clear black and white, was a colovesicular fistula. I called up the medicine attending to give her the news. “Thanks for reaching out,” she said. Now that the problem was conclusively identified, he would undergo surgery to solve it.
Even though Mr. X didn’t know the role I played in his treatment, even though I remained distanced, as I drove home that day, I felt a sense of job satisfaction that I hadn’t experienced in a long while.
As physicians, we’re forced to document and chart a lot of routine, marginally relevant stuff on a daily basis. Often we write about bad days, either our patients or our own, to process the turbulent thoughts and emotions of a tough job, to battle our burn out or fatigue. But not every day has an unhappy ending. I write this now to remind myself: It was a good day.