Your Radiologist Says: Clinical Correlation is Recommended

Your Radiologist Says Clinical Correlation is Recommended - BrettMollard.com
This article explains why radiologists frequently recommend clinical correlation in their reports and provides real world examples.

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“Please correlate clinically.” “Clinical correlation is recommended.” What do these words signify when a radiologist includes them in their report?

This blog post will explore the meaning of clinical correlation and its importance to radiology.

What is Clinical Correlation?

 

“Clinical correlation” is a term used in medicine, frequently within radiology reports, that can be taken literally. It simply means to correlate the abnormal imaging findings with the clinical findings available (medical history, physical exam, laboratory testing, and imaging studies) to figure out what is going on with the patient. Look at all of the information available and see how the unexpected finding(s) correlate(s) to that specific individual.

The goal is to narrow down a differential diagnosis to one accurate diagnosis that will account for all of the patient’s symptoms (i.e. identify the etiology that can explain the cause of the underlying medical illness or problem) and rule out other potential diagnoses queried in the radiologist’s interpretation. We say “‘a’ is present and could be secondary to ‘x, y, or z.’ Correlate clinically.” This is our way of saying that we have inadequate clinical information to differentiate between ‘x, y, and z’ as the cause of ‘a’ and we’re asking you, the ordering doctor/provider, to fill in the gaps and narrow it down to the most likely underlying cause.

While there are occasional memes (with healthcare workers jokingly suggesting radiologists overuse the phrase [at least I hope they’re joking!]), clinical correlation plays an incredibly important part to providing excellent patient care and is where the radiologist fits into the medical team.

Why is it Important for Doctors to Correlate Clinically?

 

Clinical correlation is a critical part of being a great doctor. Think of yourself as a detective. You have to be able to look at a patient presentation, take all of the information available to create a full picture of what’s going on, and put the pieces together in the way that solves the puzzle.

Keep in mind: Occam’s razor (the simplest solution is likely correct – a single etiology is most likely the lone cause) versus Hickam’s dictum (a patient can have as many diseases as he/she/they darn well pleases – more than one underlying pathology may account for the patient’s illness).

Assessing and interpreting all medical information in conjunction with abnormal imaging findings to make the best diagnosis is what it means to correlate clinically. You need to take a step back from the trees and see the forest. Look at each test result individually and the test results as a whole (e.g., T3 and T4 levels are much more useful when you have a TSH).

Clinical correlation is important because it allows doctors to make an accurate diagnosis using all the information available to them. Having a correct diagnosis will then guide appropriate treatment. By correlating clinical data with laboratory test results, imaging findings, and other information, doctors can ensure that their patients receive the best possible care. Treat the patient, not just abnormal imaging or laboratory results.

How is Clinical Correlation Used in Practice?

 

Clinical information and data are collected and analyzed to determine any patterns or relationships associated with the patient presentation. Then you let the scientific method play out. The information is used to generate a clinical hypothesis that can then be tested to prove or disprove your hypothesis. Ask additional questions, order another test, etc.

Successfully correlating the laboratory test results and imaging findings with the patient’s clinical situation and physical exam can and will help to improve the accuracy of the clinical diagnosis and ensure appropriate treatment. After all, this is why we went into medicine as doctors and healthcare providers: we want to deliver amazing care to our patients!

One of the key benefits of clinical correlation is that it helps to ensure that clinical decisions are based on the analysis of evidence. By analyzing clinical data, acquiring more data when relevant, and identifying any existing patterns or relationships, clinicians can make more/better-informed decisions that help guide management. More accurate diagnoses lead to better patient outcomes.

Clinical Correlation for the Patient

 

“I’m a patient and my radiology report says ‘correlate clinically.’ What does this mean for me?”

Great question. Our radiology reports are generally full of medical jargon and intended for the ordering doctor/mid-level provider to read and understand, but we are becoming acutely aware that patients now have access to radiology reports, which are very confusing to a layperson.

Radiologists use the following words “correlate clinically” in our reports when we’re not sure of the significance of a certain finding (what we see in the radiology exams we interpret) or when there are several possible causes for the findings we see based on the images and provided clinical history we have, which is sometimes very limited. This is when we’ll ask your healthcare provider to “correlate clinically” to see what disease process would best fit a diagnosis based on everything they know about you, your symptoms, and any underlying medical conditions you may have.

Lastly, good for you for looking out for yourself and stumbling across this article! As doctors, we do our best to help our patients and we do a much better job when we’re able to work together with our patients. Your health and well-being are incredibly important to us.

Clinical Correlation for the Referring Provider

 

A referring provider can be either a doctor, physician assistant (PA-C), or nurse practitioner (ARNP). While I can’t speak for all radiologists, I personally (as well as most of my radiology colleagues) have different expectations for generalists and specialists and try to help guide management in a way that I think is most appropriate for each patient based on this context.

For common incidental findings, such as an incidental pulmonary nodule, I simply use a macro containing evidence-based recommendations from important articles such as the Fleischner Society Guidelines for Managing Incidental Pulmonary Nodules (the article I defer to for incidental pulmonary nodule follow-up) or an American College of Radiology (ACR) white paper (articles written by experts within the corresponding subspecialty for a variety of incidental findings). I know a typical healthcare provider will know how to risk stratify a patient for likelihood of lung cancer (do they have a significant smoking history?).

Another common example is when we struggle to differentiate pathologic bowel or bladder wall thickening from underdistention, which has a similarly thick-walled appearance. Both entities can have a similar appearance and only the presence of symptoms or test results (e.g. urinalysis) can help differentiate between the two.

For less common incidental findings, we try to help guide providers with what next steps may be necessary and will frequently suggest which specialty to consult. For example, when we see a new suspicious renal or bladder mass, we’ll frequently suggest or recommend a urology consultation since a urologist is most appropriate to manage this patient. (We should be calling you or leaving a message as well – we’d hate to see something like this fall through the cracks.) If we see evidence of metastases, we’ll frequently add on an oncology consultation since that patient will likely require systemic therapy.

Clinical Correlation for the Specialist

 

In medicine, a specialist is a doctor who is specialized in a particular area of medicine. For specialists, we change our verbiage accordingly. For example, interstitial lung disease (ILD) consists of a spectrum of disease processes that I would not expect general clinicians to have a thorough knowledge of and I would recommend a pulmonology consultation to work-up newly discovered ILD when the imaging examination is ordered by a general practitioner.

However, when the exam is ordered by a pulmonologist, I expect the pulmonologist to understand my interpretation and know what to correlate for (e.g., does the patient have a history of bird exposure, a prior smoking history, etc. that will help narrow the differential diagnosis). The pulmonologist will also determine if any procedures are necessary such as bronchoalveolar lavage (BAL) or biopsy.

Another example is what to do when we incidentally find pneumatosis (gas within the bowel wall) as it can be benign in asymptomatic individuals or secondary to life-threatening bowel ischemia when severe pain is present. We expect an emergency medicine physician to check for abdominal pain and consult a general surgeon to see if surgery is necessary.

What Are Some Examples of Physical Exam Findings?

 

 

One of the most common physical exam findings we often ask for correlation for is point tenderness. “There’s a questionable fracture of the {insert bone of your choice here}, recommend correlation for point tenderness.” As radiologists, one of our biggest limitations, especially in the setting of a vague history such as “pain,” is our inability to directly assess the patient. Questionable lung opacity? Auscultate the lungs a little closer. Borderline gallbladder wall thickening on ultrasound, CT, or MRI? Push on the right upper quadrant to assess for tenderness or a Murphy sign.

Why does a Radiology Report Recommend Clinical Correlation?

 

Simply put, we use this phrase when we don’t have an adequate clinical picture and/or the findings are inconclusive. We will frequently call things “nonspecific,” which means it is not specific to any one entity, and narrowing down the underlying pathology can only be assessed clinically. More relevant medical information is needed to help explain the findings on the patient’s imaging examination which typically requires either asking patients more questions or further testing. Analysis of each test and finding can be correlated with the diagnostic dilemma within our reports and a single best diagnosis can often be made.

As mentioned above, we typically defer to “clinical correlation is recommended” when there are a few differential considerations that only the doctor/provider can decide between by looking at the individual patient inclusive of their symptoms and any existing test results.

…But Shouldn’t the Radiologist Be Able to Determine Everything from Imaging?

 
 

Oh, if only we had a crystal ball… While we are skilled in interpreting images and can often make a diagnosis from an image alone, that isn’t always the case. We want to give answers, but we don’t want to provide wrong/incorrect answers. As mentioned above, we occasionally find ourselves in a pickle where several causes of an abnormal finding are possible and we rely upon you, the ordering doctor or clinician, to do a little more detective work and solve or further narrow down the problem.

“Clinical Correlation Recommended” Examples

 

X-ray:

  • Interstitial opacity on chest radiographs → Does the patient look infected or have congestive heart failure? Pulmonary edema, atypical infection, and ILD can all be interstitial processes.
  • Subtle or questionable cortical irregularity on any bone → Check for point tenderness. A prominent nutrient foramen, overlapping structures, and sometimes just the position of the bones can look like a fracture.

CT:

  • Pneumatosis → Are there signs or symptoms of bowel ischemia? There are a lot of causes of benign pneumatosis while bowel ischemia would require emergent surgery to save the bowel. Calling all pneumatosis malignant would be far worse and result in unnecessary surgeries.
  • Questionable bowel wall thickening or bladder wall thickening → Are there signs of infection or could the wall thickening simply be due to underdistention?
  • New focal low-attenuation on a head CT → Are there stroke-like symptoms? Further testing with MRI may be warranted.

 

 

MRI:

  • Meningeal enhancement mentioned on a brain MRI report → Does the patient have a known malignancy or signs of infection?
  • Probable adenomas within the liver → Is the patient currently taking birth control? This can cause adenomas to persist or even grow. Adenomas can bleed and cause pain.

Ultrasound:

  • Gallbladder wall thickening in a patient with ascites or liver disease → Is it reactive? Third-spacing? Acute cholecystitis? They can all look the same on imaging.
  • Extrahepatic biliary ductal dilatation → Is it due to the post cholecystectomy state, an obstructing mass, or obstructing bile duct stone? The presence of pain, jaundice, and bilirubin levels will help.

Nuclear Medicine:

  • Radiotracer uptake on a bone scan in a pattern not consistent with metastatic disease → Is there a recent history of trauma (healing fracture) or an underlying metabolic bone disorder to account for the atypical abnormal uptake?

Summary

 

“Clinically correlate” is the radiologists’ way of contributing to patient management and indirectly acting as part of a patient’s clinical care team. As radiologists, we make abnormal and potentially abnormal findings all the time, but frequently the imaging findings alone are not sufficient to make a definitive diagnosis. It is here where we rely on a patient’s clinician to further widdle down the differential diagnosis – to see what best fits with the patient’s clinical picture. We ask you to help us with our limitation: lack of access to the patient. You can be Sherlock Holmes, detective extraordinaire, and we’ll be your Watson.

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