I rarely find myself diving into radiology journals, unless, of course, I need to meet Continuing Medical Education (CME) requirements. It’s not often that an article catches my eye enough to make me click through. However, this month, an intriguing study was published in the Journal of the American College of Radiology (JACR), examining how often radiologists’ recommendations for follow-up imaging align with the decisions of referring clinicians. The study noted an agreement rate exceeding 88%, a figure that initially seems encouraging. Yet, the nuances are worth exploring, as the study highlighted that certain groups, like surgeons, were less likely to agree with the radiologists.
I must confess, I didn’t delve into the meticulous details of the study’s methodology, but it did prompt me to ponder the frequency and evolution of recommendations within radiological reports. Once upon a time, it was relatively rare to see recommendations in these reports. As someone who completed my residency back in 2004, when the radiology landscape was quite different, this shift feels significant. Back then, guidelines like BI-RADS were in their nascent stages, and the Fleischner Society’s recommendations weren’t yet established. The world of radiologic advice felt more akin to a lawless frontier—each radiologist had their personal approach to suggesting follow-ups when they did at all.
We would occasionally suggest a different imaging study if we believed the one ordered wasn’t the best fit, or if another modality could better illuminate a finding. However, these suggestions were often met with skepticism. At the time, such recommendations could be perceived as self-serving or imply a lack of respect for the referring clinicians’ capabilities. There was a fear of entangling other practitioners in potential malpractice complications; if they didn’t follow our advice, they risked legal repercussions should things go wrong.
I recall being much more connected to my clinical roots in those days, and it was drilled into us that we shouldn’t request tests without a clear, actionable plan. Ordering a slew of tests as a mere fishing expedition wasn’t deemed legitimate practice. Relying on radiologists to chart the clinical path was seen as amateurish, almost an abdication of professional responsibility.
With such a mindset, it seemed audacious for me, a radiologist, to impose unsolicited recommendations on clinicians who, presumably, already had their plans delineated based on the imaging results. It was akin to butting into a chess match with unsolicited advice on strategic moves.
Yet, as time trudged on, seismic shifts occurred within our field. Guidelines became more concrete with the introduction of the Fleischner criteria and extensions under the BI-RADS framework, such as Lung-RADS and others. Imaging technology mediated faster scan times and easier access, lessening the radiologist’s role as a gatekeeper. Emergency rooms, seeking efficiency, adopted CT scanning as a triage method, while referring clinicians became increasingly swamped, often delegating parts of patient management to non-physicians.
With these transformations, the stigma surrounding frequent recommendations in radiological reports diminished, transitioning into an expectation. Nowadays, many radiologists have incorporated a "Recommendations" section into their reporting templates, sometimes out of genuine belief in its utility, other times out of necessity due to recurrent requests for addenda when such recommendations are absent. It’s likely that radiology residents today are being trained explicitly to include these sections.
Our field saw an expansion in the scope of our recommendations. Some directives remain firmly within our realm, like detailing how follow-up imaging might avoid pitfalls of previous exams. For instance, I’ve often seen follow-up chest CTs compromised by respiratory motion or ailments like asthma or COPD. Consequently, I use templates that suggest more controlled conditions for subsequent exams.
Stepping slightly beyond radiological confines, we’ve also ventured into providing clinical-related advice. Gone are the days we feared offending clinicians by pointing out possibilities that might have evaded their notice—such as unexpected dermal lesions or breast asymmetries on scans. Presently, it’s almost expected that we’ll highlight these findings to prevent potential medical crises like undetected cancer.
However, I still balk when I see radiologists advising consultations with other subspecialties, such as suggesting a surgical consultation without clarity. Does this imply the referring physician can’t handle the patient’s care alone? In such scenarios, if I decide to recommend a specialty consultation, I strive to include some rationale or guidance—for example, by suggesting the need for a tissue diagnosis or elaborating on when removal might be electively done.
Despite soaking in the evolving radiological landscape over the past decades, I’m acutely aware of my old habits. While I now include more recommendations than before, I’m cautious not to overstep, constantly aware of the boundaries of my clinical role.
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