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The Wisdom of Subjective Importance in Radiology
Experience gradually transforms an initial tendency to overcall findings in radiology to more of a reserved under calling on radiology reports.
“What was your radiology residency like?”
From a non-rad, especially a non-physician, the question is angled very differently than it would be from one of us. It is typically curiosity about how the heck we become capable of interpreting such a wide array of diagnostic imaging and performing the procedures we do. If the interest is about non-academic matters, the question is along the lines of how demanding housestaff life can be.
From one rad to another, it is more about the differences between training programs. Rad departments sort of have personalities, derived from the cast of attending rad characters and the medical centers in which they dwell. You wouldn’t expect a community college grad to recall the same experience as an Ivy Leaguer. A West Point alum would have an even different perspective.
A first order of business in any rad residency is getting to know the attendings in each subspecialty rotation. In my institution, it was standard to have at least four stints in each one, but the first round tends to make the deepest impression. Your learning curve is steepest, and that includes finding your footing with each of your mentors.
One of ours was a private practice guy who had come out of semi-retirement to live the academic life for a bit. A first-year rez in the reading room with him was virtually guaranteed to go through a certain rite of passage.
The rez would make some finding on an x-ray. It might be very tentative early on, or with greater confidence after a few weeks/months of experience. Suppose, for instance, it was “cardiomegaly” on a chest x-ray.
This attending would screw his face up theatrically. “What do you wanna give the patient that for?” He would talk about how the resident’s eager diagnosis would enter the medical record, and forever more be part of the patient’s history. It would influence all of the patient’s future treatment, maybe get the patient a bunch of unnecessary extra testing and referrals, and even increase his or her insurance premiums.
“This is all because you wanted to be smart and say the patient has got cardiomegaly. It’s probably normal.” Then the attending would go to the next case.
Lest this be misunderstood, he wouldn’t have glossed over a truly enlarged heart, or any other “real” pathology. But whereas other attending rads usually focused on correcting rezzies for underdiagnosis (missing a ditzel in the liver, failing to notice potential signs of chronic obstructive pulmonary disease (COPD), etc.), he was keen on avoiding overdiagnosis.
That could be confusing for young rezzies, who weren’t just willy-nilly throwing around diagnoses, but instead rapidly learning how to walk a fine line between overcalling and under calling. That included diagnostic parameters for when to call cardiomegaly and when not to. If you took an “it’s probably normal” attitude into a readout with the wrong attending, you risked looking like a dummy for “missing” a mildly enlarged heart.
Forced to choose between textbook guidelines for pathology, versus fudging a bit because “it’s probably normal,” most of us felt inclined to the former. We knew we had exams looming just a couple years down the line. “It’s probably normal” doesn’t show up as a multiple-choice option all that often, and I daresay nobody heading to Louisville for oral boards would have tried that phrase out in the hot seat.
I haven’t stayed in touch with many of my residency mates, so I can’t ask them how the ensuing couple of decades has treated them. From my own experience, however, and from what I see in other rads around me, “it’s probably normal” seems pretty darned reasonable in the real world. I might tweak the phrasing a bit: “It’s probably not important.”
The vast majority of practicing rads know this, if not in so many words. They learn it in a narrower scope, for instance with punctate lesions in abdominal organs on cross-sectional imaging. Could any one of them be a tiny cancer? Yes, but the chances of that are infinitesimal, and if you go around sounding alarms for them in your reports, you will not be thanked for it. We wind up saying things like “nonspecific but statistically benign.”
Why do we say anything at all? Well, some rads don’t. Others, left to their own devices, probably wouldn’t either but feel obligated to have some sort of “yes, I see it, and it doesn’t matter” in their reports lest they get dinged in QA or hassled by a referrer demanding an addendum. As one’s career lengthens, one’s ever enlarging body of work contains more and more instances of “I always include X in my reports, but I can’t think of a single time X has ever mattered.”
This gradual transition wasn’t by someone’s clever design, but it makes practical sense. Sometime early in my career, I heard it described pretty aptly: You should start off over calling things, and gradually grow into an under caller. That’s largely because you won’t know what is safe to consider “probably normal/unimportant” until you have been around the block a whole lot of times.
Some attendings convey this wisdom more clearly than others. When we presented one of my mentors with findings that he considered inconsequential, he would tell us things like “blow it off,” or “bury it in the body of the report.”Another would get irritated and told one of my year mates: “You’re being naive if you think you’re going to make all of the findings. Just answer the clinical question.”
