Addressing Diagnostic Encumbrance: the Weight of Many Findings

I was reading out a complex case the other day. It was a cancer-restaging pan scan with a bunch of things to remeasure and compare while keeping an eye out for new lesions, treatment complications and, of course, any unrelated new pathology which might happen to turn up.

Such things can take a while, lest it need saying. While I was slogging along, a couple of other tasks were buzzing around the periphery of my “to-do” radar as I measured this and re-windowed that. After I finally signed off the case, I turned to the waiting tasks. However, I felt a need to pause a moment, regather myself, and recover from the mess I had just navigated.

I have experienced this before, but the past few weeks have brought it front and center for me. The case mix telerads tend to see is not overrun with complex follow-ups of folks with metastatic malignancies and numerous surgeries. We get lots of ER stuff, inpatients with acute issues, etc. Most of it is comparatively simple. Open the case, answer the questions at hand, and move on.

There are no objections from me when it comes to receiving the more detailed stuff. I have a strong respect for the “use them or lose them” nature of my radiology skills. Keeping the complicated cases on my worklists ensures that I will always feel up to their challenge.

Still, receiving more of them than I typically have in my past decade of telerad work has clarified the mental toll they take. Emerging from a case that had a lot going on, I feel like I have just been able to put down a bunch of things I had been carrying around.

It doesn’t have to be a particularly puzzling case, nor one requiring a bunch of measurements, annotations, and comparisons with multiple priors (although those can certainly be contributing factors). Having more than a few of these cases recently, I have come to the conclusion that it can simply be a high number of imaging findings.

By contrast, think of a nice, simple two-view chest X-ray without prior studies. There are no findings whatsoever. Even the clinical history briefly notes “routine preemployment screening.” You look at it, see nothing, report it out—perhaps with your standard negative macro—and move on. Mentally and emotionally speaking, this is as light as a feather.

Now consider the pan scan for a person who has multiple medical problems and a bunch of surgeries with a whole host of details in the known clinical background and prior studies with complex reports. As soon as you open the case, you are swamped in potentially relevant info. Mentally speaking, you are picking up pieces to carry with you on this diagnostic expedition long before you start looking at the actual images. Of course, they are loaded with more stuff for you to pick up and carry.

You might recall the old bit about your short-term memory’s capacity to carry seven items at a time, plus or minus two? These numerous pieces of data far exceed that. Trying to carry them all at once is like going into a supermarket, thinking “I’m just here for a couple of things” and grabbing one of those little handheld baskets rather than a wheeled cart. Then, two to three aisles later, your basket is overflowing while you try to cram even more things into it.

Of course, we don’t do that. These days, courtesy of voice recognition, most of us have a handy monitor displaying our every uttered thought as we look through the images. A lot of dictation software even “captures” clinical info and other things that, once upon a time, we also had to dictate. Even back in pre-voice recognition days, my residency attendings taught us to write down all of our findings on scrap paper so we would have the info ready/organized when it was “TTD” (time to dictate).

However, that doesn’t spare our meager seven +/- two short-term memory. No matter how massive a volume of information we can put on a piece of paper or a screen, it is all still contributing to whatever diagnostic “impression” we are going to put forth in our report. To some degree, we are still holding all that info in mind as we figure out the big questions: Better or worse? Genuine or artifactual?

It is just like the shopping cart you might have gone back to get at the store’s entrance, overloaded with all the stuff you didn’t realize you needed/wanted. You’re not exactly carrying it all. The cart is doing that work. But you’re still aware of it as you wheel it around. You know you’re going to have to put it all on the cashier’s conveyor, get it in bags, bring it to your car, and then transfer it from your car to your kitchen/pantry for stowing away.

It’s only after putting the last item in its place—or hitting sign and closing the case—that you have that diagnostic encumbrance lifted from your metaphorical shoulders. For the cases that had a lot going on—even a messed up chest X-ray with too many tubes and lines, plus differences in positioning from priors and a boatload of abnormalities to describe—it can truly feel like you were bearing a heavy weight that is now gone.

Sometimes, before reaching for the next big burden, it’s a good idea to enjoy being unburdened for a moment. You’ve earned that at the very least.