My Life as a Diagnostic Radiology Resident

Many of my friends and colleagues think that Radiology is a cushy job, primarily involving walking into office late (sipping a nice cappuccino), spending most of office hours monitoring the financial markets, and reporting the occasional CT if I feel like working.

Unfortunately, the scenario above is fabricated. After all, there are morning clinical-radiological rounds, the high-resolution monitor is meant to read MRIs and not Wall Street Journal, and Medical Officer's pay only allows for daily 'kopi siew tai' not Starbucks. And we report a fair number of radiological studies every day.

Anyway I digress. The first year of my Diagnostic Radiology Residency Programme has been highly enriching and educational. I would like to share a few tips on the most fundamental aspect of radiology — x-rays. Whether you are an Accident & Emergency physician ordering a Chest X-ray (CXR) to exclude a pneumothorax or House Officer ordering a CXR for nasogastric tube placement, I hope you find these tips useful for everyday use, while awaiting the final report from radiologists.

"Congratulations! You have passed the national plain film test. You are now qualified to sign out plain radiographs…"

With that, I started on my journey of reporting x-rays independently. I am no expert, and along the way i have made several mistakes and garnered several learning points. Here are a few that I feel will benefit all clinicians who have to look at radiographs in their daily work.

Have a systematic approach — Atul Gawande expounded on the impact and benefits of checklists in his book The Checklist Manifesto, and radiology is no different. No matter how "busy" the film might look, always go through the SAME reading pattern for that particular type of radiograph. Every person might have a different sequence, and that is perfectly fine. For example, I always look at tubes and lines on a CXR first, while my colleagues may start off with bones / lungs / diaphragm et cetera. This helps to reduce the odds of overlooking multiple clinical significant findings on the same film, or what we term as "satisfaction of search".

Review areas — The eye sees only what the mind is looking for. Tiny pneumothoraces hiding in the lung apices, subtle free gas under the diaphragm and those tricky fractures hiding at the "corner of the film". These clinically important and sometimes life-threatening conditions may be very subtle and easily missed if one is distracted by other findings, or not diligently following his/her own personal checklist. It is often worth a second look or by zooming in on areas of interest.

Reading up — Pneumothoraces present very differently on a supine film as compared to an erect radiograph. Every tube and line has their optimal projection on a film. It is helpful to refresh your knowledge every now and then. A very crude comparison would be looking at ECGs - if you haven't looked at one for a few months, its best to revise before starting your cardiology posting. If in doubt of any imaging finding, please do not hesitate to contact your (usually) friendly radiologist Resident. We don't know it all, and personally I refer to 'google', radiopaedia and ask my colleagues whenever I get stumped.

With that, I will retreat back to my favorite workstation and continue musing over those tough cases. I hope that you will find these above tips useful!