Are the Best Radiologists Suckers?

Amid a bevy of questionable referrals for X-rays and computed tomography (CT) scans, an unwavering due diligence prevents skepticism from giving way to cynicism and a possible missed diagnosis.

I don’t naturally strike up conversations with taxi cabbies, barbers, and the like. I answer questions and act friendly enough if they get the ball rolling, but otherwise I’m liable to just sit there in awkward silence whereas others will jawbone away like old pals.

Occasionally, however, chat does happen, especially if I am with someone who is more gabbily gifted. So it was that I found myself particularly enjoying an Uber ride during my recent weekend trip to Washington, D.C. A topic of interest was the driver’s accomplished family tree, which boasted more than a couple of physicians. One of his observations was that such folks with smarts of the book often lack those of the street.

He is not exactly the first person to have made this observation, and I think some folks embrace it a little too eagerly. However, it fits a certain sense of cosmic justice: Those gifted with minds capable of a career in medicine are correspondingly deficient in other types of intelligence. Also, as I wrote in a blog not too long ago, even if a doc proves exactly as gullible as any other member of the population, others call it out when we have feet of clay in matters non-medical. (“You’re supposed to be so smart. How did you fall for that line of nonsense?”)

I do think there is a causal relationship going on here. Folks with scientific-type intelligence have learned that it’s important not to dismiss possibilities until you have sufficient (some might prefer overwhelming) evidence. If someone with “street smarts” hears something that seems pretty improbable or downright fishy, they might reflexively say “Go on, get out of here.” We science-y types might be more inclined to nod and think, “That could be the case. I wouldn’t rule it out,” while our minds churn out a dozen different possible explanations to validate whatever we are hearing.

Of course, this paves the way for more of our time and consideration to be wasted by con artists and other more benign diversions. Maybe we eventually emerge with a realization that we could and/or should have bailed out sooner or perhaps we cling to the notion that “It could just as easily have gone the other way.” In our eyes, the street-smart folks jeering at us for being taken in might have been overly dismissive or even missed out on opportunities for themselves.

A typical day’s work sees me being a sucker more than a few times. I routinely open cases with a gut instinct about how unlikely they are to be positive, whether they are abnormal in a way that the referring clinician is suspecting or revealing other significant pathology that was not expected.

As the years have gone by, certain types of study have proven to warrant a high level of skepticism (or, for epidemiology types, a “low pre-test probability”). For example, there are the X-rays for teenagers with “chest pain.” There are the head CTs on demented patients for “altered mental status” who have had a dozen negative head scans in the preceding year for exactly the same reason. In a similar vein, there are the X-rays of an entire extremity for atraumatic “pain” (no localizing details in the provided patient history of course).

While part of my mind eagerly embraces the skeptic approach, the other part—the sucker—almost always pulls rank. There are a gazillion reasons for this. Maybe this time, the head CT will actually have a subtle stroke on it, and fate is trying to throw me a curveball. Well, I’m not going to be caught off guard! Alternately, maybe this time, I will notice something on the X-ray that nobody else did before (see last week’s blog about my radiological delta).

Of course, there is a reason the skepticism has developed during my previous couple of decades of work. More often than not, I do not come up with any brilliant diagnoses. Sucker that I am, I believed that there might be something on this scan for “worst headache of my life” even though it seems like every headache coming through the scanner is claimed to be somebody’s worst ever headache.

I am happy to be such a sucker. I never want to be so jaded that I convince myself an imaging study is boring/negative before I have given it just as careful a look as I would give any other. I tend to think that patients would prefer knowing that their diagnosticians are suckers instead of skeptics.

This reminds me of one of my mentors from second or third year of medical school. Drawing a contrast between a couple of types of primary-care physician, he described a family medicine doc as someone who goes into a situation expecting things to be normal and is surprised when he or she finds pathology. Meanwhile, an internal medicine doc approaches things expecting pathology and is surprised if everything turns out to be normal. (My apologies to any family medicine doc readers who might take offense.)

I have often wondered, if I ever came across that preceptor again, what he would have to say about the diagnostic value of being a sucker. I am pretty sure he had enough of a sense of humor to field the question.