What Does a Radiologist Do?

In a nutshell, a radiologist interprets diagnostic imaging studies all day. What does this entail? Let me tell you a story.

The Neighborhood Radiologist Goes to Work

Once upon a time—each workday, in fact—the Neighborhood Radiologist awakens from his slumber, stretches his pale arms and legs, and jumps out of bed. After going about his morning routine, he kisses his wife and child goodbye, and heads to work.

Next, the brave radiologist ventures into a deep, dark corner of the hospital, to the reading room.

Man walking into a dark cave
“The way is shut. It was made by those who are Dead, and the Dead keep it, until the time comes. The way is shut.”—J.R.R. Tolkien, The Return of the King

Is he scared? Goodness, no! Invigorated by coffee and Skittles, the Neighborhood Radiologist fires up the computer, picks up the dictaphone, and gets to work.

Work primarily consists of interpreting imaging studies: X-rays, CTs, MRIs, ultrasounds, etc.. The types of studies can vary day to day, and the workload is shared with other radiologists. A computer workstation with multiple high-resolution monitors displays the studies as the radiologist scrutinizes the images, compares to older studies to look for change, incorporates the patient’s history and current symptoms into his interpretation, and verbally dictates his impressions into a magical dictaphone. Voice recognition software quickly and accurately translates (ahem, Siri) into a written report, which is associated with the imaging study. Either immediately—if findings are urgent—or shortly thereafter, the results are communicated to the physician who ordered the study, and to the patient. Time to move on to the next one!

The day is busy; the Neighborhood Radiologist must exercise his multitasking muscle. Phone calls are fielded from other doctors with questions about studies already read by the radiologist, or about what types of studies to order. Technologists performing the studies are in constant contact with the radiologist—usually while studies are in progress—to resolve issues and ask questions: “Which protocol would you like me to use on patient A? Do you need any additional images on patient B before I complete the exam? I believe patient C is having a reaction to contrast, can you come see her?” This occurs on a daily basis, with the exception of contrast reactions, which are (thankfully) less frequent.

You may be wondering why radiologists choose to work in such dark spaces. The answer lies, unsurprisingly, in the eyes. Almost all images are displayed in shades of gray (not 50 shades, more like 16), with abnormalities often just slightly darker or brighter than adjacent normal tissue. Although a radiologist’s eyes are trained to pick out these abnormalities, conditions must be ideal, i.e., it must be dark in the room. Have you ever been temporarily blind when exiting a movie theater into bright sunlight, or stumbled around in a darkened room that you entered from a lit hallway? These phenomena are a function of rod cells on your retina, which are slow to react and can essentially “burn out” when exposed to bright light. To avoid this burn out and maximize detection of subtle abnormalities, a radiologist needs to read in a dimly-lit environment.

Oooh! When do I get to meet the radiologist?

Sometimes, radiologists explore the bright spaces outside the reading room, shuffling elsewhere in the department to areas where help is needed. They may perform image-guided procedures—using fluoroscopy (real-time X-ray), ultrasound, CT, or MRI—in designated procedure rooms. Patients occasionally have questions or concerns better addressed directly before they leave, and the radiologist is happy to talk to them. The radiologist may need to check and/or treat a patient with a contrast reaction, which occurs most commonly with iodinated contrast injected for a CT scan.

Seal stretching to feel the sun
And on a warm spring day, it’s nice to feel the sunshine.

The Interventionalist and the Mammographer

Two radiology specialties that have frequent, close interactions with patients are interventional radiology and mammography.

Interventional radiologists (interventionalists) are subspecialists who use fluoroscopy (real-time x-ray), ultrasound, CT, or more rarely MRI to perform image-guided procedures. Their tools are not for the squeamish: needles, clamps, wires, catheters (long, thin tubes), hooks, and syringes. Procedures are minimally invasive, with a small needle hole or nick in the skin surface often the only evidence that something was done. As a patient, you will meet the interventionalist before the procedure and, depending on the complexity of the procedure, you will be completely awake, or mildly/moderately sedated. A large variety of procedures can be done this way, including biopsies, drainage of fluid collections, catheter placement inside blood vessels (such as for chemotherapy or dialysis), pain injections into joints or the spine, or even treatments of certain types of cancers by “burning” or “freezing”. Minor procedures can be performed as an outpatient, while major procedures often require a short hospital stay. Many of these procedures—pioneered and performed by interventional radiologists—have markedly improved patient safety and comfort.

Those of a certain gender and age will, at some point in their lives, likely meet a mammographer, a radiologist who subspecializes in, well, the mammary glands. Screening mammography is an X-ray of the breasts, performed annually on all women beginning at 40—an age that has been the topic of recent contention—by a technologist trained in breast imaging. One almost never meets the mammographer during a screening mammogram; the mammographer reads the study after the patient has gone home, and, if an abnormality is suspected, issues a “recall” for the patient to come back for further imaging. Upon the patient’s return, the mammographer orders additional mammogram images or uses special techniques, including ultrasound and MRI, to further evaluate the abnormality, and will usually talk to the patient about the findings—sometimes even performing a biopsy the same day. Mammographers also help the breast surgeon to localize cancers by placing special markers around the cancer on the day of surgery.

A few facts and misconceptions about radiology

  • THE VAST MAJORITY of diagnostic imaging studies are interpreted by radiologists. Exceptions are few: obstetric ultrasounds are often read by obstetricians, echocardiograms and cardiac stress tests are often read by cardiologists, and musculoskeletal X-rays are sometimes read by orthopedic surgeons. So, when you discuss imaging results with your doctor, they almost certainly are referencing the official report of the radiologist.
  • A radiologist does NOT PRESCRIBE your study; it should only be ordered by a doctor who has a clinical question to be answered with imaging.
  • Radiologists do not use light boxes or film anymore. You have probably seen “TV doctors” use these, pointing at X-rays films in front of light boxes—what looks like a backlit, semi-transparent photograph negative. An infamous (at least to radiologists) example occurred in the opening credits of “Scrubs”, in which they not only used this antiquated method, but embarrassingly placed the chest X-ray backwards, such that the heart was on the wrong side of the body. Well, HARDCOPY FILM HAS GONE THE WAY OF THE DODO, replaced with computers and digital images. We still have light boxes in our offices, but we use them as bulletin boards, and to hang family photos.

Radiology hard, make Hulk head hurt

People sometimes ask, “What was the most difficult part of becoming a radiologist?” In my opinion, it is learning what is normal: a feat much trickier than it seems, because every single patient has a slightly different normal. Obviously there are similarities in anatomy among all humans. However—you will have to take my word for it—your normal chest X-ray can look very different from my normal chest X-ray. This constant novelty, more than anything else, takes countless hours of formal training to learn and years to master.

Radiologists play a key role in our health care system, albeit largely behind the scenes. As a profession, we are making a concerted effort to interact more with you, the patient. Come visit us sometime! Maybe, if you are lucky, we will share some Skittles with you.

Next, explore the long road to becoming a radiologist.