Junzi Shi, MD

As a trainee, it can be confusing to determine whether or how to report findings that have little significance to the clinical question. Incidental findings in radiology include a category of diagnostically indeterminate findings that need further evaluation, as well as a category of findings that have no significant clinical impact. There has been considerable heterogeneity in reporting of the latter category, and our discussion will focus on these entities. An incidental finding, such as a simple renal cyst, duodenal diverticulum, and anatomical variants require no follow-up imaging or workup. They are benign without malignant potential. They do not impact the patient’s life; in fact, no one would realize the finding existed prior to the imaging exam. The continued rise in the volume of imaging means that more incidental findings will likely be discovered, and we will need to figure out how to deal with them.


Do incidental findings really have no impact? While a finding may not have clinical significance at the time of the current imaging exam, they may become relevant in the future. Exams are now archived in electronic servers and reports are permanently stored in the electronic medical record. The ability to quickly look back at prior imaging has made a significant impact on our ability to interpret imaging findings. In this system that codes dictations as searchable key words, documenting incidental findings may be useful for long-term patient care. For example, vascular anomalies are anatomic variants that may have clinical impact at a later time. A left vertebral artery arising directly from the aortic arch may result in neurological symptoms. Furthermore, it is important to make the surgeon aware of such variants because they might impact surgical planning for neck and chest operations. Recognizing anatomic variants and their impact is essential for radiology trainees.


Are incidental findings truly harmless? The American College of Radiology Incidental Findings Committee reported that a non-enhanced CT scan of the lower chest, abdomen and pelvis may detect clinically significant incidental findings in 5-16 percent of asymptomatic patients and a higher frequency in symptomatic patients. Further workup of these findings may change clinical or surgical management only in a small percentage of patients. For example, workup of an indeterminate renal mass with CT or MRI renal mass protocol often cannot distinguish between renal cell carcinoma (RCC) and oncocytoma or lipid-poor angiomyolipomas. Therefore it is not surprising that at surgical resection, many solid renal masses are found to be benign. Even for patients with a “radiology success story,” meaning that a renal mass was worked up with imaging, followed by prompt surgical resection of a malignancy, there can be contradictory outcomes. Studies of patients with small renal masses, specifically stage T1a RCC, have shown paradoxically increased mortality after surgery. Less than optimal outcomes have led to mounting questions about the cost versus benefit ratio of recommending further imaging evaluation for each incidental finding.


Would anyone pay more to have incidental findings of little or no clinical significance reported? A medical professional would probably say no, but a patient might say yes. In our current payer system, there is no mechanism to bill for a shorter or longer read. In fact, the current movement in radiology is toward uniform dictation templates to minimize heterogeneity in our reports. Nevertheless, as more patients get scanned and more data is generated, there may be a growing market for radiology consultation or boutique radiology, where patients may get a more personal, in-depth interpretation.


Being able to distinguish benign from potentially harmful findings is an important part of radiology training. Incidental findings are commonly encountered, and deciding how to report them continues to be a daily struggle. Evaluation of incidental findings requires considering what is best for patients. A 2016 article that introduced the concept of not reporting clinically unimportant incidental findings raises an important point that physicians make better decisions when attention is focused on the most important findings. The radiologist’s number one priority is answering the clinical question to facilitate patient care, and reporting potentially harmful findings to ensure patient safety. Overall, higher-resolution imaging and better understanding of clinical significance have allowed radiologists to become an increasingly important part of the medical team.

Articles

The Value of Incidental Findings

"It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us, we were all going direct to Heaven, we were all going direct the other way.”

Famous first quotes such as from “A Tale of Two Cities” by Charles Dickens are indelible and unique. There is a sense of timelessness and wisdom from great works of literature which is what makes generations of readers read them word for word repeatedly. An attempt to summarize the work is incapable of serving justice and risks losing its essence. When it comes to English literature, reading the original book is essential to understanding the author’s viewpoints. However, when it comes to science, does this rule still apply?

Trainees in medicine have growing responsibilities with fast-paced rotations through various specialties ranging from one to four weeks in length. This rarely allows one to spend copious amounts of time reading in depth. As we are asked to bear more duties and expected to have more knowledge, the biggest challenge is balancing clinical duties with academic ones. How do you acquire a large amount of knowledge quickly and efficiently? The challenge of “life-long learning” is how best to improve this process.[[{"type":"media","view_mode":"media_crop","fid":"63594","attributes":{"alt":"Studying radiology","class":"media-image media-image-right","id":"media_crop_1675409018039","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"8117","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 113px; width: 170px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Â©Julia Tim/Shutterstock.com","typeof":"foaf:Image"}}]]

It is simply impractical to read entire books in an attempt to cover the medical literature. However, textbooks are the most in-depth exploration of a given topic and have long been the gold standard of learning. Deeper insight is obtained by reading in greater depth. Ideas within a text are organized and presented in a certain logical or chronological order. How ideas are presented may be as important as the ideas themselves. The process of thinking about the book’s content while reading helps to stimulate mental synthesis and combination of ideas. Furthermore, making personal summaries and notes will help with memorization and understanding rather than reading someone else’s summary.

With the age of computers and digitalization of data and literature, there is an increased struggle to catch up with reading. There are over 2.5 million new scientific papers 

 scholarly peer-reviewed journals. Whereas, there used to be one dominant book which led the field and was considered THE book to read, this idea has been largely replaced by frequently updated, focused scientific papers. With the advancement of science and technology, we now publish articles at an increasing rate, which adds to the volume of literature available at our fingertips.

Trainees in turn have adapted to new demands by favoring review books rather than textbooks. However, these two types of references and methods of learning are not mutually exclusive. Strategies for digesting a textbook or reading about a certain topic includes reading backwards. Read the summary first; then go more in-depth for a topic that is less understood. This approach offers a big picture view and an outline skeleton from which one can flesh out the details. Reading backwards involves reading the summary, then headings and subdivision, then the introduction. From there, look at all the figures and figure captions carefully, and skim the text to understand the details and supporting data.

There is no right way to learn. Optimal learning for an individual probably occurs with a combination of all these tactics depending on which position on the learning curve. However, be aware that when a summary or study guide is used instead of the textbook, one may gain knowledge that is not just superficial, but wrong.  Summaries often provide an overview of conclusions and facts but do not explain how the writer came to that conclusion; it is up to the reader to do the work and make sure they understand all the nuances.

Identified and describes supporting evidence

Strongly connects new content to previous learning

Interpretation, connection, and integration result in an accurate conclusion

To Be Well-Read or Well-Summarized?

One of the best moments in my academic life was walking out of the testing center at the end of the last USMLE exam. That feeling was sweet but transient.

 grade as a radiology resident, I am still taking tests. As an advocate for lifelong learning, I figure they are part of the bargain: learn, test, teach, repeat. The purpose of tests is to provide constructive feedback to both student and teacher. However, not all academic assessments are fair nor are they effective.

It can be a daunting task for programs to provide trainees with concrete and useful feedback. ACGME requires program directors to report on resident performance annually, which includes milestones for medical knowledge and competency. The annual ACR in-training examination is one means of providing every trainee with a reportable percentage score. However, limitations to this test make it generally unhelpful in terms of being constructive feedback. Scores are biased towards the most recent rotations a trainee has passed through. The questions include a broad assessment of knowledge meant to be accumulated over four years of training, including physics and quality assessment questions. This is problematic for the younger trainees. As a first-year resident, I took the exam before experiencing several rotations, and my topic-specific scores ranged from 2% to 98%, which was both laughable and predictable.

In addition to the formative yearly assessment, end-of-rotation exams are a common way to assess trainees. These questions are typically written by one of the attendings in the department assigned as the “resident liaison,” and are supposed to address knowledge appropriate to the trainee level.  However, there is significant variability within the exams regarding the broadness of questions and how well they are written. Sometimes there is low correlation to the assigned reading or clinical work. The most effective assessments are ones that are created in conjunction with self-study, rotation-based learning, and post-assessment feedback. [[{"type":"media","view_mode":"media_crop","fid":"61392","attributes":{"alt":"Radiology student","class":"media-image media-image-right","id":"media_crop_9681801218722","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"7764","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 200px; width: 200px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Â©Phoelix/Shutterstock.com","typeof":"foaf:Image"}}]]

At the graduate level of training, there is more convergence of knowledge even among trainees who have come from different backgrounds. In this setting, tests should focus more on feedback for the trainee and using questions as a tool of improvement rather than for judgment or punitive action. One method for effective, low-risk self-assessment is to test knowledge retained from didactic lectures, which make up approximately 20% of time spent in the hospital. The low-stakes nature of lecture-based exams help to give constructive feedback without necessarily reporting to the program director. Furthermore, the act of going through the “testing-retrieval process” helps to solidify didactic knowledge. As studies in neurobiology have shown, for example by Nabavi et al 2015 in 

, induction of memory encourages long term potentiation

which counters the time-dependent loss of retained material and expands working memory. Regular didactics coupled with self-assessment exams can be geared towards junior residents, and spread out over longer periods of time for senior residents.

Shifting from the annual In-Training exam to periodic topical assessments would be a more helpful method for evaluating trainees. Formal testing is currently sponsored by individual departments. These exams lack formal peer-review and demonstrate a high degree of variability among institutions. Recent interest in developing educational tools reveal peer-reviewed national question banks on the horizon, which can be filtered by subspecialty. For example, 

 thousands of de novo questions and provide a platform for program directors to compare trainee test data with national data. The horizon is promising for improving the educational experience. Ensuring that exam questions are relevant, encouraging self-assessment, and focusing on constructive feedback are all ways to improve the learning process during radiology training.

“Essential characteristics of proficient performance have been described in various domains and provide useful indices for assessment. We know that at specific stages of learning, there exist different integrations of knowledge, different forms of skill, differences in access to knowledge, and differences in the efficiency of performance. These stages can define criteria for test design. We can now propose a set of candidate dimensions along which subject matter competence can be assessed. As competence in a subject matter grows, evidence of a knowledge base that is increasingly coherent, principled, useful, and goal-oriented is displayed and test items can be designed to capture such evidence.” (Glaser, R. “Expertise and assessment.” In M. C. Wittrock & E. L. Baker (Eds.), Testing and cognition. Englewood Cliffs, NJ: Prentice Hall. 1991:17-30.)

Effective assessment of radiology trainees.

Assessing the Radiology Trainee

Let’s play a game.  Lay your hand down on the table, and write the letter A on your thumb. Then,  continue lettering B, C, D, and, lastly, E on your pinkie finger. Now find the quickest path from A to E by connecting the letters.  One way to do it is to draw a path from A down one finger to B up the next finger to C to D to E….but you could also pinch thumb and pinkie together to achieve the same goal. The difference in methods is sometimes called linear vs non-linear thinking. Within the frame of linear thought processes, A flows to B before arriving at C, and so on. Once you lay your hand on the table, it becomes a two dimensional surface and linear thinkers tend to connect the letters by drawing a line in sequential order.  On the other hand, non-linear thinkers use “spatial jumping” and form connections in a non-sequential way. Neither is right or wrong, nor the superior method; rather, these categories are a way to describe thought processes.  In the reading room, diagnostic radiologists often employ linear thinking as a method to logically and sequentially document findings. First, there is the search pattern. As a new radiology resident, I was instructed to figure out my preferred search pattern for each type of exam and to stick with it for each patient. This organizes thought processes and creates a work flow that divides large amounts of data into digestible pieces. Furthermore, having a consistent search pattern reduces the human error of simply forgetting to look.  Secondly, we employ the linear thought process of figuring out differential diagnoses. If A, then B. If C, then D. How many times do we use this a day? As a trainee, the learning curve is to memorize imaging characteristics and differential diagnoses so that these connections can be made faster. In fact, study aids like mnemonics only work if they are memorized in a specific order, otherwise they wouldn’t make sense.  Perhaps writing “MAGIC DR” on our fingers would have been more helpful at the beginning of this exercise. Anyhow, at the start of training, both visual/motor processes and mental processes use linear thinking to process large amounts of data in an efficient and meaningful way.  Over time, the goal is to see so many cases that we know what “normal” looks like. Just as one learns to play a musical instrument or becomes fluid on a bicycle, going through the motions as a radiologist becomes natural (or so I’ve heard). What I mean by this is some motor eye movements become automatic while thought processes become subconscious. I am continuously amazed by veteran radiologists who just “have a feeling” about the image. They can’t quite explain, but they are always right.  Once, while reading out with an attending and both staring at the same image, I asked doubtfully, “How do you know that is not artefact?” and he responded, “Just trust me.” It seems that with experience and years of mastering linear thought processes, senior radiologists have somehow developed “trust” and “feelings,” or maybe some kind of sixth sense. They are no longer bound by the constraints of a linear framework. Rather, they seem to make jumps that astound the most astute memorizer (novice).  They have entered the realm of non-linear thinking. The prowess to pull together clinical data, process a few thousand cross-sectional images quickly, and to draw a conclusion that truly impacts the patient is a feat which takes years to learn. As an aside, I believe this ability is why computer-aided detection will never replace human interpretation. These non-linear connections are not described in textbooks nor included in rote memorization. They come from experience and compilation of trial and error and seeing thousands of images. I believe these connections are also the reason why we seek to learn from more experienced radiologists, hoping to glean some wisdom. They are also the reason we attend live lectures instead of simply reading about a topic. So, next time you draw letters on your hand, consider that we have opposable thumbs for a reason…which might not be evident until we appreciate all the other fingers first.  

The linear and non-linear thinking of diagnostic radiology. 

Author | Junzi Shi, MD

Articles

The Value of Incidental Findings

To Be Well-Read or Well-Summarized?

Assessing the Radiology Trainee

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