The contemporary radiologist: consultant or film reader?

diologists that “ . the proper answer as to when recommendations should be included in a dietation performed on an imaging study. with few or no exceptions. may be never. ” Radiologists will benefit from examining this statement in the context of how they interact with referring physicians and the adverse impact this policy will have on patient management. In theory. the radiologist’s goal is to optimize patient care. In practice. this occurs via interpretation of diagnostic imaging studies. The written report is the vehicle through which this information is conveyed to the referring physician. If recommendations for additional imaging procedures are in the best interests of the patient. recommendations become valuable advice. Lawson and Siegel [1J acknowledge that recommendations for additional imaging studies are meritorious for screening studies such as mammography. Why establish a dual standard? Why should physicians and their patients be penalized when the consulting radiologist eschews the opportunity to recommend additional procedures? Why wait for a busy clinician to inquire about appropriate follow-up? Clinicians, as gatekeepers. will be responsible for an increasing portion of patient management and, in my estimation. are more desirous of receiving prudent recommendations than they have been in the past. This holds true for young, inexperienced physicians and for those already established in practice who may not be familiar with the benefits of newer imaging techniques. Referring physicians generally exercise good judgment and surely will choose to either accept or reject recommendations more on the basis of sound clinical judgment than on the basis of any concerns about legal exposure. Withholding the benefit of our expertise is detrimental to the patient. Radiologists are in the best position to recommend additional imaging studies because. by definition, that is their area of expertise. Most radiologists interpret studies from more than one imaging technique. This broad-based background enables the radiologist to interpret a range of studies, provide a differential diagnosis, and recommend additional procedures when uncertainties or ambiguities arise. To withhold recommendations for additional studies raises the question of whether we are avoiding our responsibility to the referring physician and the patient. In the absence of a written recommendation. what guarantees exist that the referring physician can be notified and the appropriate procedure performed on the basis of a fleeting conversation between physicians? Is it realistic to expect another physician to have the same level of expertise with respect to the manner and means of radiologic diagnosis as that of the radiologist? What will result if the referring physician is simply unaware of the capabilities and benefits of additional imaging techniques. given the clinical findings at issue? Consulting radiologists should also look upon the written report as an opportunity to exercise sound judgment by recommending that no additional studies are necessary when findings described in a report may lead the clinician to embark on an ordering spree for what may be nothing more than normal variants or inconsequential observations. Intuitively. we know that many of the studies ordered by referring physicians are either tangential to patient management or the results are likely to be normal. In these instances. the written report should be brief and unambiguous. Radiologists. however, routinely respond to circumstances requiring additional input. If. for example. a chest radiograph reveals a pulmonary nodule or hilar prominence, the radiologist determines whether it is in the best interests of the patient to identify the abnormality, otTer a difTerential diagnosis. and move on to the next study, or to supplement this inforniation with a recommendation for additional imaging procedures such as a CT scan of the thorax. Radiologists need to assess their roles as consultants to the referring physicians and ultimately the patients. What are the medical and legal implications of abdicating the responsi-