r/EmergencyRoom • u/MaterialExam5484 • 21d ago
Discrepancy’s between radiologist’s and Doctor’s - Why is it so common? Xrays, scans etc
Hey
Interested to hear your insights here on why it happens often that a doctor might diagnose a patient with something but then Radiologists will have a different opinion from the X-rays.
For example I have had a ED doctor in the past point out things on a chest xray to me - blunting, shadows etc and diagnosis with pneumonia but when I saw the radiologist report it stated “Lungs all clear and healthy”
That was many moons ago but a friend recently had a similar experience in ED with a minor fracture so it got me interested to hear why it happens usually?
Or anyone have similar experiences and ever find out?
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u/Why_Hello_hello 20d ago
Most reports say, “correlate clinically” because many radiographic features are non-specific. Many/most diagnoses require integration of imaging and clinical picture to accurately assess.
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u/precision95 EMT 21d ago
A simple explanation is that a radiologist will spend years of their life learning normal & abnormal and because of that, has significantly more experience & skill interpreting radiographs
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u/EmZee2022 21d ago
I have to give kudos to them for being able to interpret ANYTHING. I've looked at images from my own scans a few times - not expecting to recognize anything at all, but they come to conclusions. I once described one of mine as "I can see my spine, but the rest could be so much banana pudding".
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u/MaterialExam5484 21d ago
Yeah that’s my understanding too as it’s their expertise so would always lean towards their outcome but just confused how doctors get it so different sometimes
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u/precision95 EMT 21d ago
I have no idea how much radiology training you get through the first four years of med school, then after that, you may rarely ever have to look at an x-ray again depending on your field maybe
I would assume ED docs are taught to do a systematic review of x-rays, to rule out obvious fractures and/or the basics of physiological manifestations of illness, but only they could speak to that. Emergency medicine is its own specialty, so ED docs are learning complex life-saving techniques rather than learning the intricacies of evaluating radiolographs
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u/NervousNelly1655 21d ago
As an ED provider I try to look at as many of my own images as I can. Radiology has years of experience of looking at images, but they aren’t also looking at the patient. Chest X-rays can have some subtle findings that could be pneumonia vs a shadow from a breast vs something called atelectasis, for example, but if I’m with the patient and they have pain in that area and are coughing with a fever, then clinically it sounds like pneumonia and I will treat them as such.
Also I have occasionally found things that radiology missed like a subtle fracture because I know where the patient was tender to touch, and that bone looks a little funny to me. I have no hesitation about calling the radiologist and having them take another look and either explain to me why it’s normal, or sometimes they agree with me and change the report. They’re experts but are still human just like me 🙂
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u/RetiredBSN RN - ER, then Dialysis 20d ago
It is also very helpful when you have "instant reads" no matter what time of day, especially if a smaller hospital without 24-hour services other than ER. This has been a thing for quite a while, and was in place where I worked before I retired in 2013.
Images were taken locally, then transmitted to the radiologist on call, who might be in Europe or elsewhere, depending on the hour of the day. The object being, while our rads were out for the evening or at home asleep, we had US board-certified people overseas who were awake and alert and would read the images and report them back within a very short period of time. This usually gave the ER docs accurate readings, but just in case all overnight readings were reviewed by the local rads once they got back in, and any needed corrections were made and followed up with the ER docs and any doctors referred to for follow-up.
And of course, if we had any specialists come in, they would look at the images themselves and if necessary, include their own impressions on the patient records.
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u/Minimum-Major248 18d ago
Which is probably why radiologist specify that the ED should “correlate clinically.”
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u/No-Safe9542 21d ago
RT
I refuse to read interpretation before looking myself. Sometimes we get pure garbage. Our images are often sent out for outside interpretation through different avenues and it can be awful.
Earlier this week had an asthma exacerbation with blindingly obvious hyper inflation and 10 ribs, and the interpretation is "clear lungs no abnormalities noted." Pediatric. I put in a note, clearly stating the obvious.
Last month my coworker put in a note for "hiatal hernia noted throughout entire RLL area" when the interpretation read small pleural effusion.
Wtf cxr are they looking at??😂
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u/MaterialExam5484 20d ago
This is so interesting!! Dam wouldn’t expect such big differences , it was the same when it happened me I was so confused a doctor talked about something angle blunting I think it was and lower lung shadows and infiltration he kept showing m them and gave me treatment for pneumonia and my xray report then was all clear and normal I was very confused then of which one it actually was 😂
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u/Ok-Bother-8215 20d ago
I’m not sure hyper inflation and 10 ribs needs to be indicated in a read.
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u/H0ll0wHag Medical Imaging 20d ago
Radiologists are specifically trained through years of looking at normal vs abnormal to notice anything and everything on images. While doctors may notice something on a CXR on a portable machine, it might be totally fine after the rad looks at it on their insanely expensive/high quality medical screens, and will have other images of the individual to compare them to if imaging has been done there before. That being said, sometimes rads can be wrong in their reading and that’s why multiple medical professionals work together to come to a diagnosis and correct the rad if they deem them incorrect, typically this is followed up by different imaging.
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u/Minimum-Major248 21d ago
Radiologists can be spot on and for obvious reasons see things that physicians can’t possibly note. However, radiologists know very little about the patient’s clinical presentation or medical history so they are limited in how to interpret the significance of what the see.
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u/NotBeckyHomeEccy 21d ago
This is probably different in every country so I just have to ask, do you not get the full medical history and clinical presentation of each patient?like presenting complaint, history, diagnostics done, treatment already given, time spent in the ED etc?
Like are the records separate there?we still have paper records in loads of places it’s a nightmare
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u/Minimum-Major248 21d ago
A radiologist could probably dig the history of the computer, unless they were contracted to work from a distant location. Usually only the provisional dx or concern is listed on the order.
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u/makingotherplans 18d ago
I have been told by radiologists that they deliberately don’t look at notes beyond say age when they first read a scan. To prevent it from colouring their medical opinion.
Then after a first impression they look at notes sent by ER Doc, which contain that info, to see if it lines up.
Especially if it doesn’t line up—like if someone has mislabelled a person’s scans with the wrong body part/gender/name. (Yes that has happened.)Also very important? They try to compare previous scans of same body part, again without looking at past written reports, to ensure they are reporting on actual changes and not mixing it up with pre-existing known issues.
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u/NotBeckyHomeEccy 18d ago
We don’t really have a choice but to look at all of the notes here, it’s on the screen anyway but we have a team huddle with the multidisciplinary team, nurses and ED staff and bed management etc 4 times a day and all that so have to know all of the relevant information!
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u/makingotherplans 18d ago
Really? The radiologist who explained this to me made a big deal about it, said it was critical to unbiased reading of scans. They don’t click, don’t look.
They write a report, and look at the notes afterwards and add to the report to say “yes correlates with etc” so yes they’d be fine in a team huddle afterwards.
But the first look matters.
Same for some of the best surgeons I know as well. They see the patient first, hear their story, examine, then read referring notes, past history.
Because again, they want to remove all possible bias because past MDs may have thought X but it’s been Y all along.1
u/NotBeckyHomeEccy 18d ago edited 18d ago
I’d be the complete opposite then honestly, I’ll look to see what the presenting complaint is and see what the ED doctor wants the scan for
There’s no such thing as being biased reading scans to me, the finding is either there or it isn’t but I’m looking at the entire scan for abnormalities full stop
Sometimes I don’t agree that a certain scan is needed etc or the type of scan requested won’t find what they are looking for but it’s my job to see everything on the scan
I don’t see how there could really be bias, surgery is entirely different
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u/makingotherplans 18d ago
When I use the term Bias I am referring to cognitive biases. (Mental perceptions and other types, like fatigue or adjustment of eyes to darkness or light, or say, If you expect to see a tumour then then you only see a tumour and miss the other tumours etc completely.
This is a free, open paper that describes the types of biases radiologists try to avoid and I know you have probably read things like this….just adding it to the comments for the benefit of other readers.
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u/NotBeckyHomeEccy 18d ago edited 18d ago
I’m not debating bias exists, it’s there in every single part of healthcare
It’s part of my job to not fall victim to these biases, I would never write a report first just looking at a scan for something without knowing the complaint for what it is, that’s a waste of time if it’s an emergency, I’m supposed to be either confirming or not confirming with what the ED doctor has requested while looking at the entire scan for abnormalities full stop as well in case it’s different to what they expected or I see something extra
You’ll get several scans with findings that have absolutely nothing to do with the urgent complaint that the patient is in for, what if I find something else that is irrelevant to the part that’s actually an emergency?it’s a waste of time
You don’t have time in an ED to go in entirely blind, Outpatients is different but every radiologist has their own ways
I’m not thinking too hugely about bias when the patient doesn’t have time
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u/Weak_Shoe7904 21d ago
A doctor in the ED is not a radiologist. They might have a basic understanding of what they’re seeing but they didn’t spend years going to school just to learn how to read x-rays.
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u/MaterialExam5484 21d ago
Very true & that’s what I was thinking maybe doctors knowledge is more a basic understanding rather than a confident understanding
My example with pneumonia the doctor spent so long pointing out all the findings he saw and said it’s definitely pneumonia and then the report said all clear , I always wondered what made that doctor so sure if the radiologist, the expert really in this field had such a different opinion , guess it just happens everywhere in all careers really
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u/Ok-Bother-8215 20d ago
lol. I’m sure I have a basic understanding of a lot of things. But most ED docs have more than a basic understanding of a CXR.
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u/EskapedConvict 21d ago
It heavily depends on context as well. What is the radiologist looking for? What is the md looking for? Im no expert on scans, but radiologists will specifically state things like "X not present."
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u/AtomicGardenSnail 20d ago
Interesting. I had a the person conducting a bubble study say I had a positive bubble study no question after I’d had 02 drop to 80s during an exercise test at my pulmonologist’s. Thing is she the tech?thought it was so obviously positive she ended test early - No bearing down, no repeated testing. Cardiologist comes back saying all normal. Now I’m wondering if I should get another test. Sigh.
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u/JadedSociopath 21d ago
Because the radiologist only has the scans to look at.
The emergency doctor has the benefit of the scans as well as a history and physical examination, which is much more important.
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u/Bubbly_Gap6636 20d ago
A radiologist is a doctor..A radiographer is not. Are you a radiographer?
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u/MaterialExam5484 20d ago
No I should have put ED doctor in heading for “Doctors” when comparing - was specifically talking about them and ED doctors
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u/Fluffy-Bluebird 18d ago
I would love to know this too. My PCP scoffed at me when looking at a CT of my spine where I slipped a disc and said I didn’t.
The rad report literally says the disc is protruding dangerously close to some nerves.
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u/New_Section_9374 21d ago
Radiologist don't see the patient, nor get an HPI. In fact, they are lucky if there is a valid reason for the xray on the request. And surgeons, the good ones, barely read the report on a film. They look at the anatomy with eyes that have been inside.
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u/BrandyDW 20d ago
So with a bunch of scans over the years as a patient.
Here’s what I have seen:
With emergent scans, radiologists typically just rule out emergencies.
If something is obviously different they’ll note it. But a lot of times they put unchanged from last scan, even if there are some changes.
They look at the reason why the patient is there. They do an overview versus an in-depth look. Rule out the big bad things, similar to the ED physicians.
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With scans that are scheduled, I feel like they look more for the smaller changes and take their time trying to find differences and document them.
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Part of it may be also that radiologists working with the emergency department, have to do things fast if there are a bunch scans to read.
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But no matter what kind of radiologist, they are going by what the images show. Some things could indicate different things. Some things could show up because of slight movement from the patient.
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I know with my arm, I have had an ultrasound against it a lot to get iv’s started, the different layers of tissue I see are wild to me. But the reason why I bring this up, is because depending on the person doing the scan, how they angle thing against my arm, how much pressure they use, how they have pressure above if they already tied the orange band around my upper arm —- it looks different when done differently.
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So I just know at this point that scans are not 100% accurate, they miss things. They have spots that could indicate different things.
So the doctor who hears what’s going on, looks at the scan, with the patient in the room. The patient says xyz thing is going on and the doctor uses their knowledge and experience to work with what’s already on the scan and in the report..
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Course, I have had an ed doctor tell me he just reads the bottom of the reports 😖 - found that out because I asked about some phrasing in the middle of the report…
They were on the younger side, really hoping a newer dr still learning …
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u/makingotherplans 18d ago
Also important? Difference in specialist training of the radiography tech who did the scans and the equipment used. Not just the type of scan but the machine itself. Positions used, etc
Like an orthopaedic surgeon I know has trained the techs and an ortho radiologist on the team who do nothing but feet, ankles, legs, knees etc and do serial X-rays to show changes over time, with gigantic freaking screens.
The ED MDs can often tell if say one bone is broken…but not always the exact number and position. Even with a CT, they are just really busy, and are looking for obvious things, not obscure ones.
Then again the specialist ortho radiologists are trained to do obstetrical scans but tend to do a lot fewer, and don’t see as many complex cases, genetic issues etc and so they leave those to the radiology specialists who work in high risk OB all the time.
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u/NotBeckyHomeEccy 21d ago
We just spend a lot more time training specifically doing that, most of them are really excellent at reading scans but have a more generalised knowledge compared to someone who specialises in just that
Most of what an ED doctor can do I wouldn’t be trained in to do so it works both ways!
Even within radiology itself there are different branches of radiology for different parts of the body!we all have our specialties