Keywords
Clinical evaluation - image interpretation - radiology - outpatient department
Introduction
Medical imaging provides information on extent of diseases [1] and offers wide scope for management through imaging-guided interventions. Though
it is universally agreed that elaborate clinical details help radiologists report
accurately, few studies have tested the veracity of such beliefs.[2],[3],[4],[5],[6],[7] Clinical aspect has taken backseat among radiologists, due to race against time.[8],[9],[10] Radiology has become vulnerable due to overdependence on referral clinical notes,[10] which are often sketchy.[11] This leads to inaccurate assessment, repetitive consultations and investigations,
financial burden, and loss of man-hours. To re-emphasize the benefits of clinical
evaluation and real-time monitoring of imaging, in interpreting images, this study
was undertaken.
Materials and Methods
A prospective study was carried out in the Department of Radiodiagnosis at a tertiary
care hospital for a period of 10 days during the month of December 2016. Patients
above 18 years of age (legal age for consent in India) and referred for imaging (radiography,
ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), fluoroscopic/radiographic
procedures) were included in this study. Cases referred on urgent/emergency basis
were excluded from the study. Prior to imaging, the patients were subjected to detailed
history taking and clinical examination by three in-house radiologists, randomly.
Whenever the patient was unable to provide relevant information, the accompanying
attenders/relatives were questioned and the information was sought. All relevant medical
documents of the patients were sought and studied. Thereafter, the imaging referral
sheets were scrutinized. Any additional significant clinical detail found was endorsed
in them. Based on the patient’s condition and information needed by the referring
doctor, appropriate decision on the type of imaging modality was taken, giving due
consideration to the referring doctor suggested modality. The radiologists decided
upon the type of imaging modality based on the existing norms and protocols in each
individual case. Search for recent literature was done, whenever there was ambiguity.
The decision on the mode of imaging was explained to the patient concerned. After
their approval, the patients were explained in detail about the imaging modality and
preparations required for such imaging. Informed consent was taken from the patients.
Earliest or convenient appointment was given, whenever preparations were required.
As was the norm in the department, the radiologists studied all the imaging, near
simultaneously with the acquisition of the images, at the respective consoles. Any
additional protocol, plane of acquisition, or any additional area to be imaged were
performed at the same time as recommended by the respective radiologist and with due
consent of the patient. Any additional imaging modality which is likely to give more
information or clear the ambiguities arising was explained to the patient after the
primary imaging and was carried out.
Comprehensive reports were prepared, incorporating findings noted on various imaging
modalities carried out on the patient and answering the specific questions raised
by the referring doctors. Those reports were made available to the patients and to
the referring doctors on the same day of imaging.
The radiologists explained the results to the patients/attenders personally and also
conveyed them to the referring doctors. Wherever apt and after taking the referring
doctor into confidence, imaging-guided management options were offered to the patients.
Results
One thousand twenty-four people referred for imaging to the Department of Radiology
during the study period were included. This comprised 492 ladies (48%) and 532 men
(52%). The mean age of the patients was 46.3 years.
The largest number of patients were originally referred for radiography (453), followed
by ultrasonography (320), CT (148), MRI (83), and fluoroscopic/radiographic procedures
(20). A large number of patients referred for radiography were for chest-related complaints
(223) and skeletal trauma (125). Most of the patients referred for ultrasonography
were for abdomen and pelvis-related conditions (213). The bulk of cases referred for
CT (86) and MRI scans (59) were for neuroimaging. A tabulated form of various advantages
of clinical assessment in interpretation of imaging, as found in this study, is depicted
in [Table 1].
Table 1
Benefits of clinical assessment in numbers
|
Radiography
|
Ultrasonography
|
CT*
|
MRI†
|
Fluoroscopy/procedures
|
Total
|
|
*CT: Computed tomography, †MRI: Magnetic resonance imaging
|
|
Originally referred for
|
453
|
320
|
148
|
83
|
20
|
1024
|
|
Additional clinical details endorsed
|
236
|
65
|
15
|
6
|
10
|
332 (32.4%)
|
|
Change of primary imaging modality
|
-
|
-
|
32 (changed to MRIf)
|
-
|
-
|
32 (3%)
|
|
Additional imaging
|
-
|
78
|
10
|
24
|
-
|
112 (10.9%)
|
|
Image-guided aspiration/biopsy
|
-
|
18
|
10
|
8
|
-
|
36 (3.6%)
|
Additional clinical details deemed relevant by the radiologists were endorsed in the
referral slips in 332 cases (32.4% of 1024) after detailed clinical evaluation and
scrutinizing medical documents; 236 of them were originally referred for radiography
and 65 for ultrasonography. The radiologists opined that in 176 cases (53% of 332),
this additional clinical information helped in arriving at more appropriate diagnosis.
One such patient was a 28-year-old lady, who was referred for ultrasonography of the
abdomen with complaints of severe lower abdominal pain. A history of missed periods,
which was not mentioned in the requisition, proved to be crucial in diagnosing a ruptured
ectopic pregnancy and this helped in prompt management. Another young patient referred
for scrotal ultrasonography with complaints of testicular pain, and was suspected
epididymo orchitis. On questioning revealed the pain to be radiating and colicky.
A prompt search for ureteric calculus was made and found. Scrotal scan was also done
and found to be normal.
In 32 cases (3%), the primary modality of imaging was changed after due approval of
the patient. All of these were referred for CT and were changed to MRI. The cases
who underwent such change in imaging modality were referred with clinical impressions
ranging from stroke, hypertensive and acquired metabolic encephalopathies, seizure
disorder to soft tissue tumors in the extremities. For instance, a 2-year-old child
with developmental delay and seizures was referred for CT head, which was changed
to MRI after due consultation and explaining to the child’s parents.
In 112 cases (10.9%), additional imaging in the form of imaging of an additional area,
additional imaging modality, plane of acquisition, and imaging protocol was sought
by the radiologists after the initial imaging. Such cases included endometrial malignancy,
carcinoma cervix, metastatic lesions in the liver, subcutaneous venous malformation,
etc., Numerical breakdown of such cases is depicted in [Table 2]. For instance, a 23-year-old male, who was referred for MRI of lumbosacral spine
with complaints of low backache, was found to have hydronephrosis on MRI with a near
normal lumbosacral spine. He further underwent ultrasonography and an ureteric calculus
was detected. Additional ultrasonography removed ambiguities or provided additional
information in 58 out of 78 patients (74.4%).
Table 2
Numerical breakup of cases who underwent additional imaging
|
Originally referred for (numbers in parentheses)
|
Total
|
|
Radiography (453)
|
Sonography (320)
|
CT* (148)
|
MRI† (83)
|
|
CT: Computed tomography, †MRI: Magnetic resonance imaging. ‡Sequences and planes of acquisitions over and above the routine protocol used in the
department, §Imaging of another region which the disease process known to involve
|
|
Additional imaging
|
|
|
|
|
|
|
†Sonography
|
56
|
-
|
12
|
10
|
78
|
|
†CT*
|
4
|
2
|
-
|
4
|
10
|
|
†MRI†
|
-
|
5
|
-
|
Additional sequences‡ 14
|
24
|
|
|
|
|
Imaging of Additional region§ 5
|
|
The comprehensive reports and films of all imaging undergone by the patient were made
available to all the patients on the same day of imaging. Thirty six cases (3.6%)
were offered and underwent imaging-guided aspirations/biopsies the very next day of
their report dispatch. A liver abscess detected on ultrasonography was drained under
sonological guidance on the same day. Another patient incidentally found to have an
enlarged retrocrural lymph node underwent CT-guided fine needle aspiration, which
revealed caseating granulomas.
Discussion
The widespread view held is knowledge about clinical details of a patient, improves
sensitivity and specificity of the image interpretation.[2],[3],[4],[5],[6] There are studies to show that clinical inputs improve accuracy of reporting radiographs.[3],[4],[5],[6],[7] With the advent of cross-sectional imaging and multiplanar capabilities, it is even
more pertinent to emphasize the importance of clinical evaluation in interpreting
these modalities.
Though a broader consensus is for eliciting adequate clinical details before interpreting
images,[3],[4],[5] a study by Griscom et al. in 2002, suggested that such details may bias the radiologist who may ignore some
findings or patterns to fit into previously held clinical impression. However, the
study also mentions that clinical information should be sought after analyzing the
images and this helps in arriving at a narrower differential diagnoses.[6] Another study by Berbaum et al. concluded that clinical details improves the accuracy irrespective of whether provided
to the radiologist before or after the image interpretation.[4] In the present study elaborate history taking and clinical examination were performed
by the radiologists prior to the imaging.
Studies have recommended that the referral doctors should make available relevant
and adequate clinical data regarding the patient condition, in their referral slips/digitized
form to help radiologists interpret accurately.[2],[3],[6],[11] In the present study, in addition to the clinical details endorsed on the referral
slips by the referring doctors, radiologists themselves did a detailed clinical examination
in an attempt to elicit more details. This is in line with the opinion that qualified
radiologists have their own clinical acumen, which is equal to if not better than
many other doctors.[10] An attempt was made in this study to treasure and preserve the clinical skills and
knowledge among the radiologists in the interpretation of imaging.
In the current study, radiologists decided to change the primary imaging modality
in 3.1% of cases, after taking informed cognizance of the patient. In addition, in
10.9% of all cases, radiologists recommended additional imaging to clear ambiguities.
Radiologists have the expertise to decide on the best-suited imaging modality or its
combination, in any given clinical scenario.[10] Hence, it is recommended that the referring doctors ask relevant clinical questions
to be answered by imaging and leave the choice of imaging modality to the judgment
of the radiologists.
In 36 cases, imaging-guided aspirations and biopsies were suggested and performed
at the earliest, hence extending the scope of the facilities in the department.
Another advantage perceived in this study was the reduction in the number of consultations
and visits to the health center and radiology department by the patients, thus saving
man-hours and personal finances. In this study, revisit by the patients to the Department
of Radiodiagnosis and possible re-consultations with the referring doctors and others
were reduced in at least 356 patients (34.8%). To substantiate, calling back patients
for additional clinical details/examination was avoided (17.2%). Inadequate imaging
could have led to repeated visits by patients and unnecessary imaging. This was avoided
by changing the primary modality of imaging in 32 patients (3%) and by performing
additional imaging in 112 patients (10.9%) on the same day.
In countries where there are no standardized central health registries containing
details of all the patients attending to the hospitals, it is often not possible to
trace all the patients and follow-up. Many patients end up having multiple consultations
and duplication of investigations. Hence, it is suggested that radiology departments
be more proactive and utilize that single opportunity, when the patient is referred
for imaging, to try and diagnose his/her condition accurately using the right imaging
modalities, and help the referring doctors in offering more appropriate treatment
options. This is possible if the radiologists interact with each patient at a personal
level to elicit the problems and educate patients about the scope of imaging. In this
direction, it is recommended that every Department of Radiology establish a radiology
outpatient department (OPD), which can be manned by radiologists and can act as first
point of contact with patients, prior to actual imaging.
Limitations
The impact of clinical evaluation on imaging interpretation, in terms of accuracy
of diagnosis, was not determined in this study. No comparison of accuracy with and
without availability of clinical information was done due to the ethics of not depriving
the patients of best possible care.
Due to nonavailability of expertise in vascular and neurointerventions, patients requiring
such interventions were referred to appropriate centers in consultation with referring
doctors. This adversely influenced the number of patients who underwent imaging-guided
procedures in the department, whereas the scope of radiology is even larger.
In certain cases, nonaffordability of a specific imaging modality affected the decision-making
in favor of alternatives.
The satisfaction levels among the referring doctors and patients, regarding imaging
services provided, were not objectively assessed in this study. However, no complaints
or displeasure notes were received. Further studies may be done to objectively assess
the levels of satisfaction with such radiology services.
Conclusion
Detailed history taking and clinical examination help radiologists in deciding appropriate
imaging and better interpretation of images in answering clinical questions. From
patient’s perspective, this will lead to reduction in the number of visits to the
hospital and personal financial savings. Establishing OPDs in radiology departments
can go a long way in providing more comprehensive patient care with a personal touch
and in strengthening patient–radiologist–referral doctor relationships.
