Wednesday, May 30, 2007


ED docs and radiologists have a strange relationship. For that matter, I guess most docs have a strange relationship with their radiologists. The radiologist sits in a dark cave (as opposed to the well-lit cave favored by pathologists) or at home in front of a high-resolution video monitor, reads films and scans, reports back to the ordering physician, and never sees or lays hands on the patient. They don't own stethoscopes. They are great at what they do, and, even though I read every X-ray and, increasingly, most CT scans, they are just much better at finding stuff than I'll ever be and I couldn't do what I do without them. Neither could the surgeons or the internist or the orthopedists. That being said...

The dig on the radiologists is that they are notoriously Clinton-like in their reads. For instance, I might order a CT scan to look for kidney stones and, with the report about the presence of absence of stones, the radiologist is likely to tell me about 5 or 6 other "interesting" anomalies, often termed "ditzels" or "lucencies" or "hypodensities", which I then have to explain. Any of the above might represent the early manifestations of cancer or prion associated disease so it's not something we can just blow-off.

Most are great and know what I care about, but some, well, some are not helpful at all. Some truly do represent the internationally recognized symbol of radiology, which is a weasel dressed in camouflage, sitting on a fence, next to a hedge, across the street from a bank, eating a waffle.

"Waffle-master" is a term that we give to these commitment-o-phobes. When a "waffle master" is reading films we have actually worked it out to rotate the report taking amongst our providers. It is that painful. A "waffle-master" calls a minimum of two times on all studies, and one has actually called six times to add "ditzels" and "whatnots" to an already non-diagnostic read. The burden is thereby shifted to us to explain these thingamajigs to the patient and to make sure that appropriate follow-up is arranged. Quite a trick when the follow-up recommendation is usually for a similar study to be done in three to six months and the patient is either from another town or has no primary provider. A "waffle-master" will then recommend "clinical correlation" which is just a fancy way of saying that they are hedging and all responsibility is now ours. The best we can do then is to say to the patient, "Well, it's probably nothing but could be cancer so please arrange this follow-up."

The needle-in-the-eye, however, is reserved for the poor doc coming on at 6am. If a "waffle-master" is on for rads, the bleary-eyed ED doc is sure to receive five or six reports on plain films from the prior shift where the ED doc has not seen a "ditzel" or "lucency" or "hypodensity" and he or she must pick up the phone and call the discharged patient at home and inform them that they might have, but almost certainly do not have, cancer.


  1. I am currently following up on a bunch of things that are almost certainly not cancer, but once you have had cancer people (radiologists) get even more overzealous about reading these things. One thing is probably/maybe more cancer, but the rest of the follow ups are for things that are most likely nothing and would never have been seen if not for the tests for other things. I understand that we have to be careful, but at what point does it become more harmful to have all the radiation from the follow ups than just leaving it all be (note that I am not actually asking you to answer that unanswerable question, I am just wondering as I type)

  2. My brother is a radiologist, and he is the head hedgemaster. But after 1 or 2 lawsuits regarding incidentalomas, I would too. I recently had a case where an incidentaloma wasn't followed up on and 1.5 years later something showed up, which probably wasn't even related to the first call, but the attorneys were sure it was. So just keep passing the buck to the internists if they have one, and if they don't, we are stuck with the over calls.

  3. Some years back I had a Abd CT for something that ended up being nothing but in the mean time my private doc told me the report said something about a nodule in (lower lobe of lung? Don't remember exactly now.) I've never smoked. Anyway - I reacted and wanted to know exactly what it was. My doc said probably nothing but equipment picks up incidental things that are usually nothing but they have to report it. I think he said it could be scarring from an illness - not sure about that now. the fact that I had walk in pneumonia when I was a teenager or bronchitis as an adult could've caused it. He definitely downplayed it all.

    Anyway, I did have a follow-up CT a year later and nothing had changed. So, I basically had forgotten about it.

    Hmmm... what to do? What to do? :)

    Besides, with the kidney/ureter issues i have been having the last 17 mos - I have had at least 3 CTs and I would think they would have seen it then too.

    Ok, now please lie and tell me that radiation from CTs'and cts w/contrast,KUBs,IVPs,mag III renal scans with lasix, and the radiology tests done during the OR procedures to trace the dye aren't harmful. And I have had several of each test. I might be flitting about the yard at nite and give the fire flies some competition! I wonder if I wore that little thing y'all have to wear in the ER to track the radiation would be over limit on mine? And I wonder - is birth control still necessary? :)

    Oh and from a CT last November, the report came back that I had a cyst in my left kidney (The r kidney has hydronephrosis)which I know wasn't there in previous tests and doc assured me it was nothing. Ahhh, ignorance is bliss. :)

    Long/short - guess I gave you the long - you have to do what you have to do and sometimes you just have to give it up to God. :)

    P.S. When I was working at the hospital - I would flee the area every time the x-ray tech came up with the portable. I have always wondered though if really protected by the wall between Pt and where standing.

  4. Now I'm sure you must work with me, we have exactly the same rad at my hospital. what is even more painful is when one Rad, who is on call during the night, does the prelim and the 'wafflemaster' does the final read the next day. It involves a lot of patient callbacks for nothing other than the Rad's fear of committment!

  5. Some good points raised here. First, I understand the need for thoroughness 'cat, but this one gal, well, she is just beyond the bounds of reasonableness.

    As to the radiation risks with repeated Xrays do not worry. Xrays are nothing. The new 64 slice scans however are a different matter. Lots of stuff coming out about the increased doses of rads used in these procedures so please be aware that getting your belly or chest scanned repeatedly is not a good idea. Some times it can't be avoided, but a great alternative many times is an MRI which gives no radiation exposure. See the below link to read more.

  6. Thank you 911 Doc.

    The address didn't work. I typed it exactly as you have it here. Is it possibly missing part of it?

    The first time I had a CT was around 2000 for a gastroenterolgy work up (where the radiologist reported that nodule)and then that follow up a year later. Then in 2004 for a large kidney stone. Then 01/01/06 I had to drink 2 large hideous drinks of something prior to the CT. (Everyone's heard this by now but on that New Years nite I presented to ER with sepsis,pyelonephritis and hydronephrosis due to a totally constricted ureter) Then another CT in Feb because of concern with other kidney but it was fine. And finally a CT with contrast and 3mm cut last Nov. 5 mag 3 renal scans in last 17 mos. and all the other stuff in between.

    This last year has been a bit frustrating at times. I have been trying to avoid re-constructive surgery on the ureter. Right now it appears to be healing although the hydronephrosis didn't reverse after stenting.

    I've heard that the renal scans are safer. Are regular CTs bad but not as much as the 64 slice? Oh and what about ultra sounds? Had them too. I am thinking they must be safe because they use them on pregnant women.

    So, now y'all can see why I might be giving the fire flies a bit of competition. :)

  7. ultrasound perfectly safe. the link works, i just tried it, make sure you don't double copy the 'http' part. the 64 slice scanners are now state of the art. it simply means that the scan sections are thinner but therefore they do deliver more radiation. please mention your concerns to your internist or urologist and make sure they are aware of the number of scans you have had. all of that being said, the risks or cancer from too many scans are real but very small.

  8. I too hate this waffling and I'm even a radiology resident, but radiologists waffle and overread for the same reason ER docs get a CT abd for too many "abdominal pain" complaints and the same reason they get CT abd for classic appendicitis. To cover your ass because someone will sue it.

  9. dear anonymous rads resident,
    you are, of course, correct. the ED is especially bad for shotgunning in the era of 'can't miss medicine'. then again, everyone is. please do not misunderstand however... i understand the need for waffling and CYA, but i am talking about the WAFFLE MASTER! the LORD GOD KING OF ALL WAFFLERS THAT I'VE EVER MET! if most radiologists are a 5 on the waffle meter, she pegs the needle and then breaks it off and thrusts it into my eye.

  10. You mean like the one that on a scan of my thyroid and salivary glands noticed that she saw a tiny pocket of air in my sinus cavity (or something like that) and said I "might" be at the very beginning of a sinus infection and should probably get that checked out too? That kind of stuff?

    All my follow ups for my chest are CT scans. I prefer not to think about all the extra radiation, because at this point it is better to do it and potentially find something that would almost definitely kill me than to avoid doing it for something that could kill me later.

  11. Thanks again 911 Doc :)

    The urologist does know as the bulk of the tests ordered came from him and I did mention it in passing but it is as you stated above - it couldn't be helped. The round of tests I had last fall were more my doing in that I continuously felt like there was another block and in the end I was stented again.

    He probably doesn't know about the gastroenterologist's tests or the follow-up CT, but it wouldn't have mattered.

    Suffice it to know it has been a long process and I have had this chronic condition (thanks to the 2004 kidney stone)that has to be followed up so that the r kidney isn't compromised any further.

    One last question - What about the dyes/contrast and "radioactive" stuff that one either has to drink or gets through an IV? Are they risky? I confess that I have wondered about the nuclear renal scans with lasix only because the nurses are extra careful with disposing the urine prior to foley removal.

  12. dear seaspray,
    the exposure from these materials is negligble. the big risk is anaphylaxis or dye allergy. this is scary when it happens and is life threatening but has nothing to do with radioactivity.

  13. Thanks 911 Doc - Have a great day! :)

  14. Hahahahah!!!!!!!

    "Clinical correlation required"

    my favorite phrase. Eat it suckers!
    Love, your pathologist

  15. "...weasel dressed in camouflage, sitting on a fence, next to a hedge, across the street from a bank, eating a waffle."

    Who knew drs could be so witty?!

    I love this site!

  16. anony,

    ..and it's a French weasel !!

  17. So what makes a good radiologist/pathologist?

    Making commitments?

  18. good questin anonymous. regarding pathologists i can not comment but i'm sure ETOTHEIPI can as i'm sure he knows some good patiologists.

    regarding radiologists i guess i would say someone who helps me make my diagnosis about 80% of the time. i understand that there are studies that are equivocal or non-diagnostic just as there are patients whose presenting clinical picture is confusing. nevertheless, four to five years of residency focused on radiology should allow any radiologist to be a better and more helpful reader of films or scans than i am.