To All the Overcalls I’ve Made Before

May 13, 2016

The usual suspects in radiology overcalls.

My focus in last week’s column was the phenomenon of overcalling-that is, rendering unnecessarily abnormal diagnoses-and how one might go about reducing them without willy nilly undercalling instead.

I’d mentioned some circumstances wherein a rad might encounter new information (at least, new to him), adoption of which results in him overcalling less frequently. For you epidemiology buffs, that would mean turning false positives into true negatives.

Such external validation is not the only way I’ve found myself trimming back the overcall weeds in my metaphorical radiology yard. Another, which might count as my “share” in Overcallers Anonymous, is noticing that I’m diagnosing a condition an awful lot.

For instance, let’s say “normal” is within two standard deviations of the average, and thus “abnormal” is anything beyond. This would mean an abnormality prevalence of about 5%. If I’m reporting abnormality 50% of the time, I’ll notice something’s amiss pretty quickly (and if not, clinicians referring to me certainly will).

But if I’m overcalling less egregiously, say 10%, it might take me hundreds or thousands of cases before the penny drops. Even then, it won’t hit me like a thunderclap; rather, I’ll have a slowly mounting sense of wrongness, and it might take years before this crosses some line in my mental sand that results in me changing my ways.

Also in play is the gravity of the diagnosis in play. That is, what am I adding to patient care by reporting an abnormality that may not be genuine, versus what risks am I imposing by not reporting the abnormality that might indeed be there?

Some overcalls that have thus earned places in my personal rogues’ gallery:

Cardiomegaly. Specifically, on chest X-rays, especially AP portables where the patient is supine and/or has inspired such that I can see all of four ribs above the diaphragmatic shadow. Do I still call it sometimes? Of course, if I think it’s legit. But I’ve definitely raised the bar for myself on this one.

Fatty liver. Or Hepatomegaly. (On ultrasounds, in particular.) More than half of the sonographer worksheets I receive have these two written on them. Yes, it’s tough not to report something that the sonographer is telling me s/he saw. But I also have a hard time believing that over 50% of the population is wandering around with steatotic, enlarged livers (even with the overabundance of McD’s and its ilk). It’s gotten so my first reaction to these sonographer notes is “Oh, really?” And if the images I’m given don’t prove it-if I have to choose who to believe, the tech’s note or my own lying eyes, I’m going with my globes almost every time.[[{"type":"media","view_mode":"media_crop","fid":"48579","attributes":{"alt":"diagnosing in radiology","class":"media-image media-image-right","id":"media_crop_1798611536275","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5806","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: 180px; width: 180px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"©Alex Oakenman/","typeof":"foaf:Image"}}]]

Echogenic kidneys. See above.

Thickening. (Or thickened.) I’ve gotten to semi-hate these words. Which doesn’t mean I refrain from using them, because sometimes things appear thicker than normal. Referring to just about anything-walls of bowel, bronchi, esophagus, gallbladder, arterial intima, etc. But really-if the structure should be distended and it isn’t, and especially if it has no bearing on the clinical context (which, I grant, we often don’t have)…what am I adding to the patient’s care by saying it might be a little thickened?

That “what am I adding” self-interrogation goes for my other no-longer-frequent overcalls above, and a handful of others besides. Often, the only thing an overcall adds is uncertainty, and more costly, time-consuming, and plain ol’ unpleasant additional diagnostic testing for the patient in question.

What’s your personal #1 pet peeve overcall? (Doesn’t have to be something you personally do-now or in the past-can be something you see from other rads, especially when you second read their cases or inherit their follow-up studies.)