Summary: X-rays are difficult to read and X-rays cannot see all abnormalities. So even if "normal" X-rays have been taken, this does not give your child a clean bill of health. Normal X-rays can be deceiving in this way. So if your child is not getting better, return to your doctor for a repeat check up, repeat X-rays or other advanced imaging studies, even if normal X-rays have been previously done.
First of all, X-rays are difficult to read. This is a basic misunderstanding because patients think that an X-ray is an all powerful tool that is definitive and mistake-proof. Wrong !! X-rays are sometimes misinterpreted and even when they are properly read, an X-ray is not capable of finding all medical problems in the area. The interpretation of X-rays is sometimes controversial when different specialists have different opinions of what the X-ray shows.
The specialty of reading X-rays is called radiology. Physicians specializing in the interpretation of X-rays are called radiologists. After becoming physicians, radiologists train for an additional 3 to 8 years learning how to interpret X-rays and other radiology procedures which include, CAT scan, ultrasound, MRI scan, angiography (X-ray dye injected into blood vessels), nuclear medicine, and many other high-tech complex imaging procedures. Radiologists learn their trade full time so they are very good. Don't expect perfection because radiologists are human.
Other physicians have to read X-rays as well. Pediatricians, internists, surgeons, emergency physicians, family physicians, anesthesiologists and most subspecialists all have to read X-rays. These physicians were trained to read X-rays as well, but their X-ray training was only a small part of their past and ongoing training; not a full-time training like that spent by radiologists. Therefore, non-radiologists are not as good at interpreting X-rays (they make more mistakes). During the usual work day hours (banker's hours), radiologists are available in most hospitals to read all the X-rays being taken. But during the night, weekends and holidays, a radiologist is usually not available, which means that X-rays taken after banker's hours, must be interpreted by non-radiologists. Residents (physicians in training) usually staff hospitals at night.
What kinds of patients need X-rays after hours when radiologists are usually not available? Patients in the emergency room, intensive care unit, operating room during emergency surgery and other urgent and emergency patients whose condition cannot wait for the X-rays to be done later. In other words, the most severely ill patients in the hospital are the ones who have X-rays taken when a radiologist is not available. When the most abnormal X-rays are being taken (very ill patients are more likely to have abnormal X-rays), non-radiologists are reading these. This is when errors in interpreting X-rays are most likely to occur.
While this sounds like a dangerous situation, it is not as bad as it sounds. Most board certified physicians are very capable at interpreting the X-rays most commonly ordered in their specialty. Board certified emergency physicians are very good at interpreting emergency X-rays. Board certified intensive care specialists (intensivists) are very good at interpreting critical care X-rays. Board certified neonatologists (premature and newborn baby specialists) are very good at reading premature and newborn baby X-rays. Board certified surgeons are very good at reading X-rays of surgical conditions. While radiologists are required to be proficient at reading all X-rays, other physicians must only be proficient at X-rays of their specialty. For example, neonatologists (newborn baby specialists) are not required to interpret senior citizen X-rays and adult intensive care specialists are not required to read the X-rays of 500 gram (one-pound) premature babies.
So non-radiologists just need to concentrate on learning to read the X-rays important to their specialty. Still, most of the time, radiologists will be better than a non-radiologist. However, the more important difference is that board certified physicians are usually better than non-board certified physicians at reading X-rays in their specialty.
No matter who reads you child's X-ray, realize that there is a possibility that the X-ray might be providing misleading information. If your child is not getting better, you should take your child back to the physician again. Repeat X-rays or other advanced imaging studies should be ordered if things aren't getting better. Here are some common examples:
A 12 year old hurts her elbow during softball and comes to the emergency room in the evening. An X-ray is taken which is read as normal. She is told to rest her arm in a sling. The next morning, a radiologist reviews the X-rays from the previous night and he notes a small fracture (broken bone) in the elbow. Her parents are called and an appointment with an orthopedic surgeon is made at which time a cast is applied. Her parents are upset that the X-ray was misread the night before, but this fracture is small and it actually doesn't matter if the cast is applied right away or the next day.
A 9 year old playing soccer is struck in the right hip. He says that he felt his hip pop out. An X-ray of his hip is taken which is read as normal. He does not get better and one week later, another X-ray is taken which is still normal. A bone scan (a 5 hour test) is done which shows no blood flow to his injured hip. This is a condition which an X-ray cannot detect early. One month later, an X-ray shows the damage to the hip.
A 10 year old goes to her doctor's office after complaining of stomach pain for one week. She is a ballet dancer and notices the pain more after ballet exercises. An X-ray of her abdomen is taken which is read as normal by a radiologist. One week later, her stomach pain is worse and she is also complaining of back pain. Another abdominal X-ray is taken which shows several spine fractures caused by leukemia. Her first X-ray is looked at again to see if these findings were present on the first X-ray. Yes, these findings were present, but it was only mild and difficult to see. It is fairly common to miss subtle findings on an X-ray from an unusual diagnosis, even for radiologists.
A 2 month old boy is brought to his doctor because he has been coughing and it sounds like he's choking. On examination, it sounds like he is wheezing so he is given an asthma treatment which makes him feel better. An X-ray of his chest shows clear lungs. He is given some medicine but he does not get better. He is brought back to the doctor because he has not improved. The doctor could just continue to see how things go, or the doctor could do something definitive to figure this out once and for all. Interestingly, many doctors will choose to just continue to see how things go. Most parents prefer the opposite (to find out for sure what the problem is). Doctors tend to be more patient than parents. In this case, a CAT scan of the chest is ordered. The CAT scan shows a cancerous tumor squeezing the tubes in the lungs causing the wheezing. This is serious, but remember that it did not show up on the chest X-ray. As discussed earlier, X-rays can be misread or they can fail to show serious conditions. A CAT scan is expensive and some doctors are reluctant to order one unless the condition appears to be serious. Usually, early in an illness, it may be difficult to determine that the condition is serious, because it has just started.
Be understanding when your physician misreads an X-ray, because they are difficult to read with perfection. Always follow up on your child's X-ray reading to make sure that a radiologist has reviewed your child's X-ray. And of course, if your child is not getting better, return for a follow-up visit even if previous X-rays were "normal" because a "normal" X-ray does not mean that your child is fine. Repeat X-rays or other advanced imaging methods (CAT scan, bone scan, MRI scan, ultrasound, etc.) may be necessary to make an early diagnosis.
The section below comes from an instruction sheet that I wrote for parents whose children have X-rays in an emergency room.
1. The emergency physician has read your X-ray as (for example, NORMAL ANKLE).
2. Large abnormalities requiring urgent care are generally obvious and therefore this is unlikely at this point. An emergency physician can find most of the problems on an X-ray, but the emergency physician is not a specialist in radiology.
3. To be sure, we will have the hospital radiologist (X-ray specialist) read your X-ray on the morning of the next working day (Monday through Saturday). If there is an important difference in the X-ray reading, we will try to call you or your doctor, but this doesn't always happen. To double check us, please call your physician or the hospital clinic (999-9999) to find out how your X-ray is being read by the radiologist. If you call the hospital X-ray department directly, they will not give you the reading over the phone since the medical reading is not understood by most people. It must be done through your doctor.
4. When you call your doctor or your doctor's office nurse, tell him/her that you came to the Emergency Department where some X-ray's were taken, and you were told to call your doctor to double-check the X-ray's reading with the hospital's radiologist. The most common things that are missed on X-ray readings are tiny fractures (cracks, chips, or hairlines) and small areas of infection (bronchitis, pneumonia, bone infection, etc.).
5. To be sure that these problems are not there, it is important that you contact your physician so that you will receive the proper care for this condition.