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Rodney WM, Rodney JRM,TBA

Pfenninger Chapter-Plain radiography in the Office May 10,2008 DRAFT

Wm. MacMillan Rodney MD, JR MacMillan Rodney MD, Arnold KRM

Radiology for Nonradiologists-Xrays in the Office

UPDATED MAY 10

Mark Needham MD has been teaching this at the AAFP and NPI since 1995 or longer. His perspective is Santa Monica private practice which is an over-doctored urban area. He is a graduate of the Santa Monica FP residency which formerly was a “top ten”program 1972-2002 when it was dismantled by UCLA. He trained for 3 years as a radiology resident prior to joining FP.

We appreciated the tremendous amount of work he has done in creating and refining the 13 hours of lecture he presented in San Antonio. We discussed how our private practice experiences are equally valid but different. For example, MEDICOS no longer recommends “casting” torus fractures, and prefers the simplicity of splints. Other style differences are noted below. Dr. Needham’s presentation and the courtesy extended by NPI reminds us to thank these entities in an acknowledgement.

Dr. Needham repeatedly punctuated the chest series with “normal” views., and then cases which were clearly “abnormal”. His 3 years of radiology training led to a perspective which is somewhat different that the one we have developed. For example he stated, “When the elephant’s in the room, you have to ignore him[until you have made sure that you don’t miss any other abnormalities], and “Look beyond the obvious pathology”. This raises the question of how much time should the clinician spend and does it add value? For our practice, once the elephant is detectedwe go to the hospital or splint/cast.

He recommends over-reading every film by radiology, but allows that the MEDICOS style of selective consultation is valid. The fear of “not missing anything” is universal but creates a slippery slope ultimately leading to analysis paralysis. His handout states, “Become a radiologist”. I don’t think we can ever resolve this dilemma to the universal satisfaction of everyone. Maybe #6 in the second section should be moved up on the list, but we cannot spend too much time on philosophy and politics.

Dr. Needham stated that the most commonly needed skill is the ability to interpret a chest film. Therefore, ”Interpretation of the Chest Radiograph” is a section which stands on its own. This section would include our one page medical record form as a strongly recommended guideline. With image examples, this chapter starts with a brief introduction about this technology as an essential [nonoptional] keystone in the practice of community medicine.

TC or PC or both Add explanations

INTRODUCTION—The acquisition and interpretation of an image is a procedural skill. These diagnostic skills require special equipment and have been identified as distinct procedures by the Current Procedural Terminology system[CPT-4]. This chapter is a reaffirmation of the role played by non-radiologists in the interpretation of images. Assuming similar proportions for non-radiologists’ Medicare claims in 2003 and similar proportions for total personal healthcare expenditures, $1.17 billion was paid to non-radiologists for musculoskeletal and chest radiography in 2003. Using 1993 Medicare data, Spettell and associates estimated that 73.2 percent of outpatient radiographs of the chest, spine, pelvis, hip, and upper and lower extremities were performed and interpreted by nonradiologists.6 While using 1991 claims data from a private insurer, Levin found that 70 percent of office studies were performed by nonradiologists.7

Studies on imaging outcomes have documented quality of care with a particular focus on family medicine and emergency medicine.This chapter will focus on the adult chest film and the principles of purchase, maintenance, and staffing of equipment in the private practice office. This is a compendium of advice found to behelpful over 30 years of teaching and practice. Our published data suggests that consultation is helpful on 2-5% of cases.[Ref]..

Guidelines are not “standards of care”. Medico-legal risk cannot be eliminated, but it can be minimized by timely application of procedural skills such as interpretation of images at the point ofservice. The clinical advantage of bedside correlation and subsequent follow-up cannot be overemphasized. At times, the clinical suspicion of lung cancer has been sufficiently high that we have obtained consultation despite a “normal” chest radiogram.

Family Medicine is one specialty that has defined itself as a specialty distinct from radiology. Residency training is sufficient to interpret images when needed, and/or seek consultation when needed. These levels of comfort vary from physician to physician, and should not be micromanaged by remote authority. The content has been reviewed and is consistent with the world’s literature. Generally, “Ten percent of the information makes over ninety percent of the clinical difference.”

THE EXAMPLE OF CHEST RADIOGRAPHY

Demonstrating and explaining guidelines for expected documentation operationally defines a summary of skills needed to maintain quality and survive audit.Quality improvement and professional development occurs through the use of a written interpretation for each case. Procedural skills require the ability to multitask while controlling for equipment, technique, probability, and the skill of each individual physician. One example is shown below[insert Figure 1], and it is followed by text explanation for each step.

Figure 1—

One page form recommended for practice. Please feel free to copy and use in your office.

INTERPRETATION OF THE CHEST X-RAY

Method of Wm. MacMillan Rodney, M.D., FAAFP, FACEP--Original 1992, Updated May 11 2008

Please fill this form out completely. This improves quality of care for the patient.

I.CLINICAL CONTEXT—Date of Exam ______Patient ID#______

Patient ID#/Name______Age:______Sex:_____

Old Films Available for Comparison?YesNo

REVIEW OF SYSTEMS (circle those that apply)

Cough Dyspnea Pleuritic Pain Chest pain Hemoptysis HTN

Other Illnesses, signs, or symptoms______

DURATION OF PROBLEM in days, weeks, or months______

II.VALIDITY—Does the image need to be repeated? Yes No

Technique usedPALateralAP PortableDecubitus

Is this film rotated?YesNo

Is there an adequate inspiration?YesNo

Is the amount of penetration within normal limits?YesNo

III.Survey the bones and soft tissues. Significant abnormalities?YesNo

IV.Is the appearance of the mediastinum within normal limits?Yes No

V.Review the cardiac silhouette. Any significant abnormalities?YesNo

VI.Review the diaphragms. Any significant abnormalities?YesNo

  1. Lungs

A.Are there any significant abnormalities on the left or right hilum? YesNo

B.Any significant abnormalities to the lung parenchyma?YesNo

C.Any significant abnormalities to of the lung pleurae?YesNo

  1. Review the lateral image.

A. Any abnormalities of the anterior clear space or posterior cardiac space? Yes or No?

B. Any other abnormalitiesYes No

IX. My interpretation is:

  1. Within normal limits.
  2. Normal, but I want to comment on some findings which are probably insignificant. Consultation not required.
  3. Questionable findings exist and consultation will be requested.
  4. Abnormalities which require comment at this time include the following:
  5. None
  6. Others, please list______

X.-----MY PLAN IS

XI.----SIGNATURES--Student/Resident:______Attending Physician: ______

INTERPRETATION GUIDELINES FOR THE ADULT PA AND LATERAL CHEST RADIOGRAPH—“HOW TO DO IT”

Include ten images of “top ten conditiions’ for illustration

I.CLINICAL CONTEXT

The clinician who performs the history and bedside examination has a tremendous advantage compared to a radiologist remote in time and space. The immediacy of these data differentiate imaging as an adjunctive diagnostic procedure for the patient in real time versus a radiologic consultation which arrives on a piece of paper. The bedside examination, review of systems, and past medical history increase diagnostic accuracy. Additionally, extenuating psychosocial circumstances such as schizophrenia, noncompliance, and uninsured status differentiate “best” academic management from what is realistically available in the community. Physicians at the point of service have the medicolegal responsibility for management of the patient in real time. Radiologists do not.

II.VALIDITY

Physicians must understand the differences among imaging options such as postero-anterior[PA], lateral, antero-posterior[AP], and other views. Ideal views are not necessary to gain useful information, but a disclaimer describing technique limitations must be inserted with every film. For chest films, the acronym RIP describes the characteristics of rotation, inspiration, and penetration[aka exposure]. Images must be labeled and dated. These validities must be addressed prior to any other interpretation.

For example cardiomegaly definitions are different on PA versus AP views. Without a lateral, lesions in the retrocardiac and poststernal[anterior clear space] space can be missed.

Is this film rotated?Yes or no? Measuring the distance from the spinous processes to the medial heads of the clavicles is recommended. Allow for the usual case where there is 2-3 mm of rotation. Slight rotation does not invalidate the film. Generally this is a good test of fundamental anatomicalknowledge. Without this the physician should stop.

Is there an adequate inspiration? Yesor no? Inadequate inspiration is a cause of decreased sensitivity for lung parenchyma. There is “best” method of counting visible ribs by counting posterior ribs as they join the spine. A minimally adequate inspiration uncovers nine. Avoid ranges and counting anterior ribs which are less predictable.

Is the amount of penetration within normal limits? Yes or no? This is a word for describing the amount of radiation exposure applied to the tissue. A practical rule of thumb of evaluating over-penetration and under-penetration is the anatomicalpoint at which the vertebralinterspaces are no longer visible. Over-exposure-penetration burns out the ability to see the lung parenchyma and vessels; ie turns the lung fields black. In an over-penetrated PA chest image there will be a “spine film” with all elements of the vertebral bodies visible down into the abdomen.When penetration technique is ideal, inter-vertebral spaces disappear somewhere in the cardiac shadow and do not appear beneath the diaphragm.

In the lung fields, excessive penetration will obliterate the visible vessels which normally start to disappear as they approach the chest wall. Needham has state that usually extend two-thirds of the way toward the chest wall.

There is a requirement to comment on limitations of interpretation as caused by suboptimal technique. The physician of record has the right to request additional views or insert a disclaimer about techniques. This includes the need for a lateral image.

III.Does a survey of the bones and soft tissues reveal any significant abnormalities?Yes or no? This area is of limited value when the indication is dyspnea, cough, hypertension, and other routine cardiovascular issues.We have not seen a case of litigation for failure to diagnose coarctation of the aorta due to rib notching on a previous film. A systemic sweep ob ones and soft tissues is mandatory.

EXPLAIN--

IV.Is the appearance of the mediastinum within normal limits?Yes No

The physician cannot miss a shifted or widened mediastinum. An exact numerical dimension for “wide” is not known. The mediastinum cannot be too thin. ROCCO-KELLY find the reference for wide.

V.Does a review of the cardiac silhouette reveal any significant abnormalities? Yes or no? ROCCO-KELLY WRITE THIS

EXPLAIN—Cardiomegaly, and chamber enlargement, thin heart of deep inspiration[COPD]

VI.Does a review of the diaphragm reveal any significant abnormalities? Yes No ROCCO-KELLY TURN THIS IN TO ENGLISH

Explain—Rhigher than left usually 5-10 mm. Can see abnormal elevation due to lung atalectasis or effusion; can’t miss airunder the diaphragms

VII. Lungs

A.Are there any significant abnormalities on the left or right hilum? YesNo

ROCCO,KELLYEXPLAIN –Left is always higher than R; finding the center of an ambiguous mass is clinical judgment

B.Any significant abnormalities to the lung parenchyma?YesNo

ROCCO,KELLYEXPLAIN—Describe visual ping-pong method to detect flagrant asymmetries, cover obvious[hemothorax, metastatic nodules,sarcoid, primary TB, etc] and the “not obvious” mild viral pneumonias, subtle TB, etc.] briefly; Comment on vessels approaching but not reaching, the chest wall. Explain the normal taper of vessels as they head cephalad in the lung fields, and then give an example of “cephalization of flow”

Explain the “freshman forest” on the R where vessels can give the appearance of a pseudo infiltrate. On the left side symmetry is hidden by the heart shadow.

Disease patterns “air space disease” vs interstitial disease”

Distinguish benign granuloma from solitary nodules from masses

C.Any significant abnormalities to of the lung pleurae?YesNo

ROCCO-KELLYEXPLAIN—Can’t miss pneumo

VIII. --Review the Lateral image

  1. Retorocardiaac and anterior clear spaces OK?YesNo
  2. Any other abnormalitiesYesNo

IX.--My interpretation is:This is the heart and soul of the “free range community physician method” Intial focus in on “normal or not normal”

A.Within normal limits.

Findings you don’t want to miss-- shifted mediastinum, widened mediastinum, pneumothorax, air under diaphragm

B.Normal, but I want to comment on some findings which are probably insignificant. Consultation not required. ______

C.Questionable findings exist and consultation will be requested. This could include a CT of the chest which is the most commonly ordered test for ambiguous finding on the plain radiograph. Consultation reports can be ambiguous to wrong. CHF can appear to be pneumonia and vice versa.

D.Abnormalities which require comment at this time include the following:

  1. None
  2. Others, please list______

X. --MY PLAN IS----This is a key advantage of offering an interpretation or a ”preliminary interpretation” in the office at the point of service. Risks of missing something are less frequent than poorly worded or ambiguous interpretations which arrive days after the patient has left the office. With the best of intentions some physicians fail to pick up messages and/or staff may sign for a registered letter only to lose it. The beauty of imaging is the high predictive value of a positive. Specificity is high when lesions are obvious, and delay of management pending formal interpretation is not wise.

The risk of a false negative[low sensitivity] is always present. Multiple studies have documented that failure to diagnose a lesion of significance is less than 1-2% .

Student/Resident:______Attending Physician: ______

Date:______

THE NEXT SECTION STILL NEEDS TO BE WRITTEN BUT WE HAVE AGREED UPON AN OUTLINE WHICH FOLLOWS.

COMMENTS FROM 8 May 2008

Rocco, you got a nice start on this, and I love the internet learning resources which remain for further editing and comment. Since our initial assignment, we have been redirected.

Our section editor, Mike Petrizzi MD, suggested that this has to be incredibly brief and very practical. There may not be room for anything but a few examples and a reference to our website. The website may offer a performance based learning drill which leads to a test for self assessment: Here is a proposed outline for the second part of the chapter. #1 and #6 will probably go at the front of the chest section.

  1. Why bother? How does plain film radiography add value to patient care in the physician’s office?
  2. Define the prevalence of conditions for which this technology is useful. The book already has a chapter on fractures, so we probably can use chest radiography as our example and refer to the chapter on fractures.
  3. Family Medicine-ER is a different issue which might be mentioned parenthetically.
  4. Define the risks of failing to have this technology in the office.
  5. We can use frequencies from the JABFP 2002 study declaring 1323 x-rays during the study year 1997. Medicos 2006 there were approx 800 billed xrays collecting $34,000 in a population 97% Medicaid and uninsured. During the study years each office saw approx 30,000 office visits.
  6. Medicos Memphis and Nashville data are available from the software 2006 and 2007. This allows a frequency calculation for almost 100,000 visits.
  7. Basically the Medicos experience suggests that musculoskeletal complaints are a frequent need in offices where “open access”, as recommended by the “Future of Family Medicine” project, increases the number of urgent carevisits. Xray frequency is 5-10 per 100 office visits.
  8. How much does the installation of equipment cost? Research the retail and used prices for equipment.
  9. We have received one equipment quote of $60,000 with aprobable $10,000 cost forinstallation of alead lined room andsubsequent state inspection.
  10. This quote included digital cassette technology which excludes the need for a processor, chemical, film storage, and environmentally safe disposal of chemicals.
  11. Has digital radiography changed the cost/benefit ratio?
  12. Yes
  13. But why and how? You already mentioned some of this in your first draft.

Digital radiography offers an opportunity forcommunity based physiciansby providing lower cost, higher reliability technologyin the office. It eliminates several cumbersome aspects of traditional film. The space that developers, darkrooms, and films (both exposed and unexposed) occupied can be more efficiently used for patient care. This technology also promotes safety by eliminating developer chemicals that must be stored and disposed. By decreasing the number of retakes, radiation to patients and office staff is reduced. Finally, images are easily stored and can be shared more quickly and efficiently, which prevents unnecessary repeated studies and minimizes expense and radiation exposure.

Installation requires planning and cost-benefit analyses that must include the following: Radiographic department design; equipment, maintenance (routine and unexpected); lead planning (room lining, body shields, operator barrier); patient and staff safety; staff training (many states require that X-rays be taken by a certified technician or physician.)

  1. What is the reimbursement that the family physician can expect from Medicaid, Medicare, and others? Where is the break even point for profitability? Medicos data will be helpful here and Jack’s book on reimbursement will be cited.

--TC or PC or both? Add explanations

  1. What is the regulatory expense?
  2. Can non-radiologists legally own equipment and interpret images?
  3. Using your Tennessee experience, can physicians legally perform plain radiography?
  4. Can office staff perform imaging? Do they need a state license and any training/certification? Doctors are assumed to be knowledgeable in kVp, mAs, etc. In our experience, a medical license qualifies the physician to press the button, obtain the image, and interpret the image.
  5. What is the storage requirement for images?
  6. What is the medico-legal risk of interpretation?
  7. Should all films be over-read?
  8. Should some films be over-read?
  9. Should the licensed physician obtain consultation according to clinical judgment?
  10. Can or should the physician contract with a remote interpretation service?
  11. What is the experience of Medicos 1999-2009 after 300,000 visits?
  12. Others

ROCCO INITIAL DRAFT