The Montage

Many reading physicians believe that marking key images is a time-consuming service for referrers and patients. However, when utilized properly, the montage improves the efficiency and accuracy of image interpretation, as well as communication with referring physicians and patients. It is most useful for reading cross-sectional imaging exams, particularly in patients with comparison exams. To understand why, let’s compare reading with a montage versus reading without a montage.

Without a montage, the reading physician views the images in each image series from current and comparison exams while dictating the exam. Even with the use of speech organization, when reading this way, the reading physician has no time to gather his or her thoughts, so dictation is often longer and less organized than is ideal. Often, while dictating, the reading physician redundantly pages through the same series several times and may inadvertently fail to fully view other series. When the interpretation is complete, there is no single location where the entire “imaging story” is quickly accessible by future reading physicians, referrers, or patients.

When the montage is properly used, however, there is a paradigm shift. The reading physician uses the montage as a working notepad of images, collecting the key images from the current and relevant comparison exams that form the basis of the report and are responsive to the indications for the exam before starting to dictate the results. This concept is reinforced by the adage, “First read and only then report.” The montage is a working instrument, not just a collection of images. To be most useful, the montage must include images from serial exams that are stored together with the primary exam. It therefore “tells the patient’s story.” It is often useful to arrange the order of images in the montage to best illustrate the progression or regression of disease. It may be useful to show the same images twice on a montage, with one uncropped version to provide orientation and one magnified, annotated version illustrating the pathological finding. When the montage is properly used this way, the key findings and changes are already pictorially summarized before dictation begins. One can then dictate the exam without repetitively paging through images. The dictation tends to be faster, more organized, and more concise.

In addition, when the patient has a follow-up exam, the montage from the prior relevant exam can be displayed first per a hanging protocol. Since the montage can contain images from multiple relevant exams, this means that when reading a new exam, the reading physician gains a quick image summary of the patient’s prior story via the montage as well.

Finally, the patient and referrer benefit from the montage. For example, imagine a CT of the chest, abdomen, and pelvis in a patient with three prior exams, perhaps resulting in a total of 3,000–4,000 images. A single montage helps users who are not adept at viewing all these images immediately see the relevant findings from serial exams when the exam first opens.