Critique of Situation X-Ray Analysis and Radiographs - Term Paper Example

Introduction Radiography is believed to be important in helping to overcome the many challenges that are faced by clinical imaging services. In the UK the services provided by radiographers is recognized in the medical fraternity and the regulation of radiographers is undertaken by the Health Profession Council (HPC) and the radiographers are required to register with this body for them to be allowed to practice in UK. Society and College of Radiographers (SCoR) believe that radiographers can play a crucial role in ensuring that healthcare organizations are able to deliver effective, timely clinical imaging. SCoR published a report to assure health care providers that radiography reporting was safe and their employers/contractors followed the guidance given by SCoR. Structured report and its improvement in communication ability was noted in the American College of Radiology 2007 Intersociety Conference. After the conference there was a workshop in 2008 organized by Radiological Society of North America (RSNA) where the current state of structured report was addressed and a road map to adoption of structured report in radiology was suggested (Khan et al, 2009 p853). In the UK there is a clear guide line of becoming an advanced practice reporting radiographer or sonographer. It is required of the radiographer to have a postgraduate level of education and training which is recognized by the College of Radiographers (CoR)(The college of radiographers2004A; 2004B ). This programmes are advanced from the initial education and training of the radiographers, and there is concentration in development of clinical skills and knowledge of disease, trauma processes and their manifestations. The other areas looked at are medical image interpretation theory and process which includes errors, signs and symptoms, clinical history; the previous and/or current diagnostic information which may originate from imaging or laboratory testing and multi-disciplinary consultation and communication (The college of radiographers;2003; 2008). Such programmes have practise reporting modules which require supervision by a consultant radiologist or a qualified radiographer who is highly experienced with the programmes culminating in formal clinical examinations that one must pass. Currently there is a format that is to be followed in writing a radiological report that has been put forward by European Society of Radiology (ESR) (2011), the Royal College of Radiologists (RCR) (2006), and the American College of Radiology (ACR) (2005). According to this format there is need to have a concise summary which gives clinical history, and the clinical question is put forth by the referrer. Where this information is not available then this is to be noted in the report. If the images are not meeting the desired standards, then this need to be stated as this is likely to have a negative effect with regard to accuracy of the report. All abnormalities are to be described in a systematic manner with what is regarded to be the most important points that corresponds to the clinical question being given first. It is a requirement that in reporting there should be use of anatomic, pathologic and radiologic terms with incidental findings being incorporated in giving the description. There is need for comparison with previous studies with their reports being made if this is seen to be appropriate. The report is to have a conclusion that gives a diagnosis that can be described as being accurate and precise and where appropriate to the case it would be necessary to have a discussion of differential diagnosis. In the report a further study may be suggested where appropriate in conjunction with any urgent instructions. Case Study One As noted in RCR (2006, p7), the chances of obtaining a true and accurate report depends on the referring clinician having provided information on the request form that the clinician thinks will come in handy when it comes to the interpretation of the radiographic images. The clinical information which has been given here is seen to be incomplete. The information that is given is a recent fall. This would be expected to involve direct trauma to the patella. Difficulty in walking has been mentioned but no mention of feeling of pain and swelling. Bosmans et al (2011, p581) conducted a study where the conclusion was that availability of clinical information was likely to bring about improvement in the diagnostic accuracy in the radiographic process. Another observation that has been made is that having insufficient clinical details on the request forms may bring about interpretation errors, a result of which may be administering of treatment which is not appropriate, resources being misused or this could even lead to litigation. The author of this report fails to report that there is omission of some important information which is in contradiction with the observation made by Hall (2000). Wilcox (2006, p33) has linked most of malpractice lawsuits with lack of clear and effective communication of results or failure in diagnosis. This normally arise when the reporter fail to follow the expected radiological reporting format. The abnormalities are to be described in a systematic manner with what is regarded to be the most important points that corresponds to the clinical question being given first. This was adhered to where the answer to most important question was given first this being the fracture of the patella. The type of fracture was clearly described as non-displaced and the exact anatomical location being given as the inferior pole of the patella. The other findings were then mentioned afterwards this being soft tissue swelling and highlight of the fact that there was no effusion. The description of the findings has been noted to be the main body of a typical report. There is need for the radiologist report to come out clearly as opposed to hiding by use vague and ambiguous statements (Bosmans et al, 2011, p580). Using hedge terms Hall (2000) attributes it to avoiding commitment. The reporter is seen to have passed this test as no use of hedge terms has been noted. In the report the answer to the main clinical question has been given where there has been explanation for the difficulty in walking. Spira, cited Berlin (2000, p1516) noting that unclear description of findings with no reasonable conclusion doesn’t add anything positive and it may be taken as being an attempt by the reporter to distance themselves from the clinical issue that is to be addressed. According to Wilcox (2006), the result of not having a conclusion with a definitive diagnosis or any suggestive follow up examination leaves the referring doctor without any recommendations or consultative information that could improve the care of the patient, possibly leading to delay in diagnosis thus leaving the clinical question unanswered. The report clearly shows where the fracture is located. This is important as management of the patient would depend on the type and location of the fracture. Suppose we had a different report where type or location of fracture was not accurately mentioned, then this could have resulted into a different management. If, for example, there was a complete displaced transverse fracture at mid section of the patella, it would call for internal fixation or at least tension type band. The report failed to mention the projections of radiography as being AP and lateral. Case Study Two Going with the observation by RCR (2006, p7), the chances of obtaining a true and accurate report is dependent on the referring clinician having provided information on the request form which the clinician thinks will come in handy when it comes to the interpretation of the radiographic images. Just as in case 1 the clinical information which has been given here is seen to be incomplete. The information that is given is that the patient was involved in a fight. The clinical data clearly suggest trauma but there is no mention of pain, swelling, limited movement which are to be the expected clinical findings. Bosmans et al (2011, p581) conducted a study where the conclusion was that availability of clinical information was likely to bring about improvement in the diagnostic accuracy in the radiographic process. Another observation that has been made is that having insufficient clinical details on the request forms may bring about interpretation errors a result of which may be administering of treatment which is not appropriate, resources being misused or this could even lead to litigation. The author of this report fails to report that there is omission of some important information which is in contradiction with the observation made by Hall (2000). In the report it is mentioned that there is fracture of the head and neck of the second metacarpal bone and the volar angulation that involves the distal part. This is a clear conformation of requirement that in reporting there should be use of anatomic, pathologic and radiologic terms with incidental findings being incorporated in giving the description. The report shows inadequacy in terms of duration of the fracture not being mentioned; even though there was high chance that it was a recent fracture. In the report given there has been partial answering of the clinical questions but the details have not been mentioned including the type of fracture, onset, displacement and the involvement of related joint. It is also noted that not all the abnormalities were mentioned in the report. There was another fracture that involved the mid shaft of the proximal phalanx of the index finger, and this could probably be an old fracture (chronic onset) with evidence of healing, mild dorsal angulation deformity with no displacement. If the report could have been different there could have been alteration of the management where for example by the report stating an old fracture, little would be done. On the other hand a recent fracture with displacement could have served as an indication of open reduction and internal fixation. From the report it is evident that the radiographer has some background in medicine, as he/she has linked the patient complain with the major finding in the film. On the other hand the short report that lacks details but being able to highlight the main findings is a clear indication lack of clinical background. Case Study Three The clinical data that was give for this case was detailed and sufficient and this made correlation between radiographic findings and clinical information to be easy and efficient to reach the desired diagnosis. This is in conformation with the observation made by Bosmans et al (2011, p581) when he conducted a study and came to a conclusion that availability of clinical information was likely to bring about improvement in the diagnostic accuracy in the radiographic process. Also from the observation by RCR (2006, p7), the chances of obtaining a true and accurate report is dependent on the referring clinician having provided information on the request form which the clinician thinks will come in handy when it comes to the interpretation of the radiographic images. There was suboptimal positioning where the patient was observed to have slightly tilted to the right side and this can be seen to result to inadequate film quality. The inadequate film quality has not been mentioned which is a contradiction of requirement as observed in Bosmans et al (2011). According the findings of the study by McLoughlin et al (cited Dogan, 2010, p183) it was revealed that sometimes radiologists don’t pay sufficient attention to the requests of the clinician who referred the patient. In the report there has been clear identification of all the abnormal findings, with description being given in details and they have been linked the clinical data which has been provided and thus enabling a diagnosis to be reached that gives explanation to complain of the patient (FAI). The observation by ESR (2011) notes the need of the radiologist being familiar with radiological abnormalities and the associated significance. In the report there is mention of lucent lesion at the femoral head that was observed in the radiograph which had been taken earlier in 2010 and this ruled out any possibility of osteolytic metastasis from his lung cancer. The report was able to give answers to all the clinical questions with all the details being given. Other abnormalities were also mentioned in the report such as the old fracture and pubic ramus even though this had no link to the present pathology. Some radiologist are most likely to omit such abnormalities due to what is referred to as bias of a ‘satisfaction of search’. This is where there will be a tendency by the radiographer to terminate search for abnormalities upon finding an abnormality. The shortcoming that comes with such bias is that there is attempt by the radiologist to answer some specific question (ie OA). Gunderman (2009, p563) raises the concern that if the radiologist is only interested in answering the referring physician’s question, then there is a chance of overlooking other important findings. In the report there is suggestion of a line of management in view to the diagnosis and the age of the patient. It is clear from the report that the reporter has a wide medical knowledge which was clearly noted in the entire report, with description of all findings leading to the diagnosis. He made use of the clinical information that was given and his experience as a radiologist, he revised the old radiographs to ensure thoroughness and high level of accuracy in the diagnosis in addition to considering the possible line of management. The management could have taken a total different turn suppose the report was less detailed and the patient would have likely been required to undergo MRI. MRI is recognized to be a much more sensitive method to be used in situations such as early diagnosis of AVN of the femeral head as opposed to using the standard radiographs, bone scintigraphy or CT (Yeh et al ,2009, p563). Conclusion A radiographic report is considered to be a key form of communicating important clinical information. It is of great importance that such information is communicated in an effective and systematic manner. From this report it is clear that there is a need for a well-structured, concise report conforming to some form of format consisting of the clinical question raised, imaging techniques that have been used, comprehensive description of findings, and a conclusion along with any additional advice. Also it has been noted that radiography is a field strict regulation where one should have acquired a certain level of qualification. Improvements in communicating this information have been suggested including the use of structured reporting, “giving the potential to reduce ambiguity and increase confidence in the findings.” (ESR 2011). References AMERICAN COLLEGE OF RADIOLOGY (2005) Practice Guidelines For Communication of Diagnostic Imaging Findings. American College of Radiology, Reston. Available at http://www.acr.org [Accessed: 15 February 2014]. 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