Diverging Knowledge-Boundaries

Maybe a year or two ago, I wrote a column about an observation/philosophy of mine. The idea is that, at some point in (usually adult) life, folks settle into either a convergent or divergent approach to things. If you’re convergent, you’re gradually narrowing your focus. Some would say this means getting less flexible, more limited in terms of comfort-zone, while others would say more specialized and aware, playing to their strengths.

If you’re divergent, your scope is broadening. This, again, can be spun positively or negatively. Positive: You’re constantly learning, exploring, and seeking new experiences, maintaining an open mind. Negative: You’ve got no particular focus or mission, and never really dive deep into any one thing.

One area that seems especially prone to convergence, whether one likes it or not, is scope of expertise in diagnostic radiology, or indeed healthcare. Once out of residency, chances are that your daily work will gradually winnow away whatever ability you had with radwork that isn’t a part of your routine.

Take interventional procedures, for instance: If you’re not doing them, it won’t be long before you have no business trying. Mammo even makes a point of it with MQSA: If you don’t read a certain number of cases per year, you’re not supposed to be doing them at all until you review a bunch of cases to get back up to snuff.

There are grayer areas. Suppose you’re a general-rad who reads most of what crosses your worklist, including nucmed. But it’s maybe only once a year that, say, an octreotide-scan shows up. Maybe sometimes it doesn’t even hit your list; someone else grabs it. How long will it be before you get rusty enough that you decide you shouldn’t be reading such things?

Back in residency-training, budding rads might not quite appreciate just what a fleeting, yet golden opportunity they have to be exposed to everything, with a department full of attending-rads who can show them the ropes and a caseload to see an abundant variety of how different types of pathology can appear, as well as what “normal” looks like.

Then-poof! It’s out into the real world. Maybe sometimes you have a coworker who’s a maven in an area of interest, who can help you with individual cases here and there. But unless you go to the trouble of finding a pseudo-fellowship or board-review style conference to brush up on some of your skills, you’ll never again be sitting alongside a mentor while a parade of cases in a particular area of interest goes by in front of you both.

And really, that’s how most of us gain our rad-skills best/fastest. We learn by doing. Sure, you can read books and journals, and there’s more reference-material online than ever. But that’s not a series of cases that may or may not be abnormal, upon which you can go through the motions of interpreting a case and then finding out whether you were right, wrong, or somewhere in-between. Most often, the cases shown are a single image, or maybe a handful, showing the pertinent findings. Hardly a simulation of your usual 100-image CT, where you’re scrolling through and hoping to find the abnormality (if it’s there).

So, what can you do to re-create that experience of looking over multiple studies, coming to your own conclusions, and then seeing what someone else thought of them to check your results?

Well, if you happen to be working in an academic institution, it’s easy. You can go to case-conferences and sit behind the residents and fellows. Or take a smidge of your free time and shadow some colleagues in their reading-rooms (if they’re amenable, of course).

Otherwise, I suppose you could simulate the experience in your own reading-room, when your workflow permits, by pulling up a list of already-read studies. Look through them, jot down your thoughts, and then read the reports which were rendered. Is this HIPAA-kosher, looking over the studies of patients whose care you had no role in? Maybe not. (Let the record show, Mr. Government-regulator, that I am not recommending this, nor do I admit to ever having done it myself.)

Or, more decidedly playing by the rules, you can make use of that ol’ nasty beast, QA. Yes, QA. Never thought it might turn out to be your friend, didja?

But it just so happens that you’re required to go over a certain number of cases other folks have already read, on a regular basis. Who’s to say you’re only allowed to review cases that are solidly within your comfort-zone? Maybe you, Dr. Nucmed, will make a point of reviewing a shoulder-MR each time you’re doing your allotment. Or you, Dr. Mammo, will pull up someone’s arterial Doppler for double-reading.

It won’t happen on its own. Following the path of least resistance, your probably busy workday will bombard you with a million things you already know how to do. To be sure, you’ll constantly be sharpening your skills within your comfort-zone, but the boundaries of that zone will probably gradually converge/diminish over a course of years.

If you’d rather it didn’t, now is the time to be proactive about it…and start finding some cases you don’t really know how to read (yet).