ACR practice guidelines could cut both ways

Last year at RSNA, I took a different approach. I signed up for three day-long courses based on case reviews. They were very good, but I won't do that again. Good lectures on topics like interventional radiology and pediatric imaging are available throughout the year at a variety of venues. By attending these courses, I missed out on many of the sessions that are unique to the RSNA meeting. Next year, I will go back to my old system of taking only a few scheduled courses and concentrating on special focus items and critical issue talks. These are the RSNA's forte.

The case-based course was very good. The instructors used an electronic Audience Response System to foster participation. It is harder, though not impossible, to fall asleep if you have to answer a question every two or three minutes.

About a thousand handheld gizmos were given out in the class. Each case prompted a series of multiple choice questions. The audience had 15 seconds to choose an answer by pushing the corresponding number on the gizmo.

Once the votes were in, a bar graph display of the tallies immediately appeared. Most questions got a few hundred responses, which means half the class was asleep or too stupid to figure out their gizmo.

Each time I voted, there were four possible outcomes:

1. Everyone in the class got the right answer. If my choice was not a guess, I could feel good that I was on par with my peers.

2. The answers were spread like shotgun pellets across the graph, but I got the right answer. If my choice was not a guess, I could feel even better knowing I was a little above average.

3. The answers were spread like shotgun pellets, and I got the wrong answer. Whether or not my choice was a guess, I feel stupid and hope the guys next to me didn't see me vote.

4. Almost everyone in the room got the right answer, but I did not. If my choice was not a guess, it should have been.

Unfortunately, my day-to-day practice works pretty much like this, too.

In spite of so much time in courses, I did hear an interesting debate about the American College of Radiology's guidelines for practice.

The mammography lexicon and standards were a particularly hot issue. I always thought it makes sense to have a standard language for reporting. The problem is lawyers.

Lawyer: "I see you discovered a 2-mm nodule in Mrs. Lowly Victim's breast on a screening mammo."

Me: "Yes."

Lawyer: "And by the time she had special views, saw a surgeon, and had it excised, it had swelled to nearly twice that size."

Me: "Yes, I believe it was just under 4 mm when they took it out."

Lawyer: "So, if you had not ignored the national standards for your profession, if you did not send out reports your own Professional College would say are bad, if you had called this terrible lesion a "mass" instead of "nodule," poor Mrs. Victim might have been rid of this rapidly growing tumor sooner. Tell me, Doctor, should we assume you ignore all the standards of your profession, since you clearly ignored these?"

Me: quiet babbling and drooling.

Standards and guidelines are a good thing, but they are clearly a two-edged sword. You may be practicing good radiology, but, apparently, you can still get skewered if you do not follow the standards. This is not a particularly comforting thought, but it is the kind of thing I usually hear first at the RSNA.

Dr. Tipler is a private-practice radiologist in Staunton, VA. He can be reached by fax at 540/332-4491 or by e-mail at btipler@medicaltees.com.