Missing the Point

Freshly returned from a much-needed vacation, the radiologist was harshly welcomed by the pile of stuff which regularly accumulated in his absence: notices of expiring credentials and licensures, CME-credit quotas, reminders of other upcoming deadlines...and, of course, peer-reviewed cases in which he had allegedly "missed."

Not particularly full of himself, the rad nevertheless knew that he was pretty darned accurate, and his QA stats were comfortably ahead of the curve. This afforded him professional pride and some degree of reassurance that he might get sued a little less frequently than others with less stellar performance. He also had the notion that, sometime in the murky future, good statistics might make a difference in gaining or keeping a desired job...or some sort of quality-based payment, should such a scheme ever be implemented. He took this stuff a little more seriously, therefore, than maybe he really needed to.

Only one case needed his attention in this regard, part of his mind happily noted. Another part murmured that, if he could successfully argue that this was not a miss, his record for the quarter would continue to be without blemish. He opened the file.

Oh, he silently groaned. That case. What a nightmare it had been. Middle of the night, an uncooperative centenarian with multiple medical problems had been pan-scanned for "R/O path." No contrast had been given, there was motion artifact everywhere...the rad had gotten way behind in his on-call workload deciphering the borderline-nondiagnostic mess. Path had most definitely not been ruled out; rather, he had been hard-pressed to find anything decidedly normal. His report had been three pages long.

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So...what had he supposedly missed? There was no indication in the file. He left a message for his colleague who headed up the peer-review program. Half the morning went by, during which the unresolved issue buzzed gnatlike around the edges of the rad's consciousness, before his call was returned.

After the obligatory "how was your vacation?" banter, the rad brought up his case. What had he supposedly gotten wrong? Was it the subcentimeter abscess he had seen, nestled between unopacified bowel loops? Answer: No, that was a good pickup.

Was it the subtle worsening compression-fracture he had identified (missed by the interpreter of the patient's previous scan)? No, that was also a good pickup. Very diplomatically worded so as not to get the previous reader in medicolegal hot water, too.

Was it the slowly-enlarging saccular aneurysm he had reported (again, not identified by the previous case's report)? Or half a dozen other bits of pathology, some of which had also been previously missed? No, no, no, no, no, no, and no.

Okay, so what did he miss?

His colleague told him that his peer-reviewer said he had failed to report a 1 mm pulmonary nodule. Additional wrangling eventually revealed that the alleged nodule, in the rad’s opinion, was part of a small blood vessel, rendered indistinct by motion artifact.

He couldn’t help but inquire as to whether, even assuming the nodule was real, it should outweigh all the other more important issues he had managed to diagnose. Should this tiny thing make the sum-total effect of the case into a black mark on his record?

“Don’t worry,” he was told. “It’ll only count as a minor miss.”

He managed to end the conversation without saying anything he might regret later.