Teleradiology has changed the landscape for the veterinary radiologists in ways that we are only beginning to appreciate. This is the second part in a series discussing these changes and how veterinary radiologists can remain relevant, foster our relationship with our referring veterinarians, and continue to make a living in the world of teleradiology.  Please do not shoot the messenger. These essays are observations made working with dozens of radiologists, hundreds of vets, and reporting thousands of teleradiology cases.

In theory/in reality
In theory, a radiology report should be short and sweet. It should discuss abnormal findings and that is all. No comments need to be made regarding normal findings. Conclusions are drawn and a list of rule outs is offered. These types of reports are common (and accepted) for radiologists working in referral hospitals and at universities.

In reality, if that is all you offer your  teleradiology client you will be out of business because your client will be left unsatisfied and wanting. Calls asking questions about reports will be numerous and frustrating for the teleradiologist.  Pet owners who receive the reports will feel cheated (many vets give the reports to the pet owners).  Last, and certainly not least, other radiologists viewing the report may criticize your work (very sad and very true).

The origin of the disconnect
We all learned in our residency that radiology reports should only discuss abnormal findings yet during our boards examination we are encouraged to describe normal findings.  The reason for this is that we wanted there to be no doubt in the mind of the proctor that we read the entire film, we needed them to understand our thought process, and we had to prove to them that we were worth ACVR certification. My bet is that there is no radiologist that has ever taken the oral boards who said “lesion on the distal radius. Rule out neoplasia vs. infectious vs. other.”  and left it at that.

The world of teleradiology is very much like the oral boards examination - with each report we must prove to the veterinarian that we are a valuable part of case management and the money they spent was worth it.  Without proving your value in each report, the perception by the RDVM is that you are a nameless, faceless machine who is cranking out reports as fast as humanly possible*. The only record of the time and energy you put in the case is the words on the page. If you spend 30 minutes on a case and ultimately say “normal abdomen” the perception of the client is that you took 7 seconds on the case.  This situation is very much different than the reports that are offered at a university or at a referral hospital.

At the referral hospital or university setting, the relationship and value of the radiologist is proven to their colleagues each day during discussions about cases. Colleagues in these situations work with the radiologist intimately, and understand the radiologist’s thought process. Many times, cases will have been discussed with the radiologist and the radiology report is, more or less, a summary record of the important points of the discussion that may or may not even get read.  At a university or referral hospital, therefore, it is not necessary to include any more than direct observations in a radiology report.

In a teleradiology setting, however, radiology reports are an essential tool to prove that you CARE about the case. Reports are, in effect, little marketing opportunities to show the RDVM that you took the time with their cases. Reports are also a way to educate the client and give them MORE VALUE than simply a list of observations. Reporting only the abnormal findings will result in unnecessarily short reports and a disconnect between the amount of time and energy you put into a case and the perception the veterinarian has for the value of the report.

In conclusion, a one line sentence describing a normal thorax or quickie report describing a complicated situation, although they may be medically accurate, will result in a loss in the perception of value by the client, a lost opportunity to strengthen the bond with the client, and a situation where you client will look elsewhere as soon as someone else comes along to read their cases for a dollar less per case than you do.

The new report
As stated previously, the new radiology report is, by necessity, a tool to help with patient management, as well a tool to show value to the referring veterinarian that you care about the case and a way to prove to the vet that you are more than a commodity cranking out reports. Every radiology report is marketing opportunity and that marketing opportunity will be perceived as positive or negative – there is no middle ground. To enhance the value in your reports, the following can be included even though they don’t technically need to be included in a radiology report.

• Discuss normal findings. Mention of normal findings, although not necessary, will show the referring veterinarian that you actually took the time to look at organs that may not be abnormal. From a practical point of view, taking a few seconds to discuss normal organs will reduce the number of phone calls that you receive that say “did you look at the kidneys…spleen…etc.?” For most vets a 2 paragraph report describing a normal thorax is more satisfying than a report that says “normal thorax.**”
  
  
• Discuss normal findings that are commonly confusing for referring veterinarians.  At a minimum, these observations can be used as mini-CE experiences to create value for the RDVM. Examples include: 
  • Widened mediastinum in bulldogs or why right-sided heart enlargement is not present in a bulldog.
  • Note accessory centers of ossification as normal findings
  • Note the trachea if elevated due to the positioning of the head during radiography.
  • Laxity of the trachealis membrane
• Discuss your thought process behind why you are making a decision or ranking rule outs. For example, it is a very different experience for a veterinarian to receive are report that says, “A pulmonary nodule is present in the right caudal lung lobe. Rule outs include neoplasia vs. abscess vs. granuloma”  versus saying “A pulmonary nodule is present in the right caudal lung lobe. Isolated pulmonary lesions in this location are most commonly due to primary pulmonary neoplasia such as carcinoma. Moreover, the sharp margins indicate that neoplasia is more likely than an infectious lesion, which is expected to have ill-defined margins. Ultimately, however, histopathology is necessary for definitive diagnosis.” As you can see, both of these conclusions say the same thing but one is infinitely more valuable to the RDVM.

I liked the old way better but the old way is no longer an option
Please understand that I am not promoting this type of report nor am I recommending this type of report to the referring veterinarians.  Rather, these observations are made after talking with hundreds of veterinarians about their teleradiology experience, responding to irate veterinarians and asking why they are upset about reports, and having vets contact us for teleradiology services*** when they are not happy with their current radiologist.

Personally, I would much rather go back to the days of simply saying “NSF” for a normal study. Fortunately or unfortunately, this is not an option. Your competition is dictating 2 paragraphs reports for every normal thorax, mentioning normal findings, using each report as a CE opportunity, creating value for their clients, and strengthening the relationship with their clients with each report. Failure to do this will result in attrition in the number of clients sending you cases

Bottom line: In the teleradiology world, veterinarians do not see what we do and to create that value, we must adapt or die. That adaption requires a change in the way we approach radiology reports.

*because most vets do not have a relationship with you, there is no loyalty in veterinary teleradiology. This is precisely the reason why local radiologists who do ultrasounds in referring vets hospitals, give lectures on the national circuit,  or show up at local VMA meetings and give the RDVM a chance to put a name with a face likley have a much higher retention rate and get the benefit of the doubt when compared to a national teleradiology service.

**This goes for many vets – not all of them. Some vets do not want to sift through 2 paragraphs of observations about normal findings. However, I can GURANTEE that no vet will ever complain about lengthy reports if the conclusion says ‘normal thorax” because they can just jump to the conclusion and skip the rest. Conversely, you WILL lose clients if you try to do this with everyone. Err on the side of caution. An analogy can be made to wearing a tie to an interview. Nobody is ever going to criticize you for overdressing. Conversely, if you show up looking like a shlep you might get away with it but you leave yourself open for criticism. Put on the tie. Trust me.

***our policy is to always contact the radiologist before accepting their clients in our service. As such, you already know about these cases if they were your clients. If we did not contact you – no worries, we are not reading for your clients.