Of Diseased Livers and Uteri: How to Read a Radiology Report
Every time I undergo a CT scan, I am rewarded with a troubling new ailment. After the physical, emotional and spiritual abuse I caused my liver during college, we still remain friends. I find it ironic that now – after children managed to interfere with the Olympiad alcoholic feats of my younger days and cancer pretty much ended them altogether – my radiologist has not once but twice come to me with reports of cirrhosis. Both my liver and I were appalled and offended.
Most recently, my radiologist has accused me of having a uterus – and a grossly normal one at that. I can live with a uterus, although I would submit that my having grown one is anything but normal. But I simply cannot abide the idea of a grossly normal one. Is it gross, or is it normal? These two words are not compatible. Vomit is gross, normal is bland. A vomity uterus? Not normal.
Aside from their mischievous tendencies to assign patients with new and diseased body parts, evidently just for the sport of it, radiologists produce reports about the growth of your mets that are as unreadable and alien as hieroglyphics. No two reports are alike. Each seems to measure different tumors, and measure them differently. None uses the same language – one man’s grossly normal is another man’s unremarkable. We had rather alarming growth in the lymph nodes near my esophagus reported in several previous reports, whereas the last report didn’t bother to measure them at all. I’ve poured over the reports alongside my various oncologists, and at one time or another each of them, after a long and studious silence, has breathed out and confused sigh and said, “We have got to get rid of that stash of ‘medical marijuana’ down in radiology.”
“I’m sorry, Chris, according to this report you have an elf growing inside your spleen and he has the munchies.”
Dena and I have lobbied to have my uterus removed. On paper, at least. And if not that, then during my next surgery. If not mine, then maybe hers. It just seems wrong for us both to have a uterus. One’s gotta go.
We’re still often frustrated by the discrepancies in the radiology reports in terms of tumor growth. For the first time, we’re unsure of our next treatment path, so we have spent quite a bit of time studying the patterns of progression from the last several CT scans. The problem is: There are no discernible patterns. If you were to read my radiology reports, you would not know with any certainty whether my cancer were progressing or regressing or was possibly just a bad case of heartburn. You certainly wouldn’t be able to follow the growth of specific mets.
So, in an effort to learn how radiologists go about reading CT scans and writing their reports, Dena and I snuck into a national board meeting of the Radiological Society of North America that was being held here in Washington, D.C. Our hope was to be able to report back to you via our blog how to better read your own radiology reports.
What we learned was rather disturbing. Below is a transcript of that secretly recorded proceeding:
Current president of the society enters room, sits without comment and glares at the other nine members at the table. After a painful few moments, he reads with a thick and enraged voice from a stack of documents in his hand.
President: In the lower left lobe of the right lung, a 3.1 cm tumor shows growth from a previous size of 2.8 cm. With ill-restrained disgust, he tosses the document to Radiologist 1 at his left.
President: Subcarinal lymph node measures 4.4 cm, an increase from previous measurement of 3.8 cm. Raises eyebrows at Radiologist 2 sitting three seats down the conference table.
President: Spleen is normal. Liver is normal. Pancreas is normal. Looks to Radiologist 3. Normal? Like you even know what @$#%&*! normal is??
President: All tumors stable. Hurls document in the face of Radiologist 4 sitting to his right. Seriously, what the @$#$%^&! is that supposed to mean?
Long, awkward silence feels room. Fear is palpable.
President: Every one of these reports – every one – is written in plain language. Every single one can be read by anybody. Including the patients, you imbeciles! Think you’ll have a job long if the oncologists and patients can just confer with one another? The President steps up, locks the door and returns to his seat, placing a loaded revolver on the table before him. Nobody’s leaving this @!#$%^ room until every one of you understands how to write like a post-doctoral literary critic. Let’s take each of these documents in turn. How do we make them more mediciney sounding?
Radiologist 5: Sir, a school of thought has lately arisen suggesting that radiology reports should actually make sense.
The President cocks his revolver, pointing toward Radiologist 5 and flicks the weapon toward the door. Radiologist 5 stands and leaves the room. The President returns gaze to radiologists remaining at the table: Continue please.
Radiologist 6: Well, Jim says that there was growth from a tumor in the right lung – from 2.8 to 3.1 cm. Why even reference the first measurement? Just make a note of a tumor being 3.1 cm, kind of out of the blue.
Radiologist 4: Forget the word tumor, even. Let’s refer to them as nodes.
Radiologist 1: What the @$#%%! is a node?
Radiologist 4: How should I know?
President: Brilliant – nobody really knows. But call it a node sometimes, a nodule other times. Nodular. Yeah, use nodular as if it were a noun.
Radiologist 7: Can we say opacity?
Radiologist 7: Why not? We’re radiologists, man. We can whatever the @$@#%&* we want.
Radiologist 2: What if we use different words to describe healthy organs. Instead of saying “normal” – glances condescendingly at Radiologist 3 – we say things like “unremarkable” or “patent” or that it “enhances” well or isn’t “suspicious.”
President: I have no idea what you’re talking about, Stan. You beautiful man, you. See me after this meeting about a raise in your salary.
Radiologist 8: What if we start listing out tumors – er, nodular opacities – in bullet points, one right after the other, so that it looks like it’s perfectly straight forward, but each time we write up a report we list completely different nodal thingys? Same bullet point formats, utterly different results every time.
President, excitedly: Wait wait wait wait! Sometimes you use the bullet-point format, other times you write in long meandering paragraphs with no punctuation. Like Jack Kerouac on crack!
Indignant, Radiologist 9 stands up and looks from man to man around the table. An American flag hangs on the wall behind him: I’m embarrassed to be in the same room with the lot of you. What are we, a bunch of sophomore English geeks? For god’s sake, we went to medical school for like 18 years; of course we can’t speak or write like normal people. We need to be bolder. Freakier. Dangerous, damn it. We need Lady Gaga on tour in Central Europe. We need sexually transmitted diseases.
An audible gasp in the room.
Radiologist 9: You heard me right. We start making up diseases and tossing them into reports like so many bread crumbs in a Hansel and Gretel story. Like this: The spleen is patent, the pancreas is unremarkable, the patient’s history of cirrhosis of the liver unchanged, heart is not suspicious, left kidney within normal limits.
Radiologist 1: You just drop in right in the middle, without comment.
Radiologist 9: That’s right, that’s the key. Talk about not being suspicious, right? Next up: Syphillis. Chlamydia. Cancer’s the last thing these guys are gonna be worried about when their wives see these reports.
Radiologist 1: Throw in some lung cancer?
Radiologist 9: Sure, why not? Ebola. Elephantitus. Polio – let’s bring back polio.
The President is sitting back in his chair, flushed: I’m feeling aroused. You guys have surpassed my wildest dreams. We’ve moved from incoherent to outright debauched. He pauses. Okay, we’ve got five minutes left before we need to leave for our dinner reservation at Western Sizzlin. We need to make a final push. Go where we never thought we could go. Pauses again. For a little motivation – next person who offers a suggestion that isn’t completely insane I shoot through the eye with my revolver.
Nobody moves. After a moment the President looks to Radiologist 1: Barry, give me something or I shoot you anyway. In the kneecap.
Radiologist 1 holds his breath for 47 seconds before breathing out forcefully and, like a man with Tourette’s, shouts: Transexuals! Uteri!
The President is visibly startled: I’m sorry?
Radiologist 1: Um, I mean, if we can just go around giving random people new diseases, why not give them random new organs?
Radiologist 2: You mean, like just throw in references to an extra appendix or something like that?
Radiologist 1: Yeah, why not? But go big, I say. Give a dude a vulva, a woman a scrotum or something. I’m going slip a uterus into my next patient’s report.
Radilogist 9: Make it an effing “grossly normal” uterus, dude!
President looks to Radiologist 1: Jim, you may have just single-handedly saved our profession – you evil genius, you. Here, take the revolver. Shoot anybody in the room. Go ahead, it’s fun. You’ve earned it. But hurry up, I’m hungry.