The Fine Art of Being Wrong

November 14, 2015
Eric Postal, MD

Reaction to errors in radiology is just as telling as the actual errors.

Nobody likes being wrong.

Or do they? I might be wrong for having made such a generalization. Somewhere out there, there might be individuals who would protest that they find being wrong a challenging, even exciting, opportunity to recognize their own limitations, and learn from their mistakes.

For the rest of us, being wrong (especially when others are aware of our errors) is an experience of varying unpleasantness. Even when it occurs outside of venues such as health care where innocent mistakes, or even alleged-but-unproven imperfections, can get one sued, censured, or suspended from their livelihood. To say nothing of the impact of a wrong move upon the well-being of our patients.

Much like a golf swing (I was running by a golf course when thinking about this column; otherwise, choose your own metaphor), being wrong isn’t just about missing the ball, or hitting it poorly. There’s a backswing and a follow-through surrounding the moment of wrongness, which will impact perception of the wrong itself by witnesses and even the wrongdoer himself.

Some common prewrong and postwrong maneuvers I have seen:[[{"type":"media","view_mode":"media_crop","fid":"43348","attributes":{"alt":"radiology mistakes","class":"media-image media-image-right","id":"media_crop_1882525814150","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4720","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: 160px; width: 160px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"©Pretty Vectors/","typeof":"foaf:Image"}}]]

Blamecasting. Commonly seen in radiology reports as a litany of limiting factors for each study (patient motion, positioning, lack of contrast, etc.). Also regarding lack of relevant clinical history or unavailability of previous imaging or reports for comparison. Much of which is often legitimate to point out…even when not specifically responsible for the wrong. A radiologist wrangling with a study that is rendered 10x more challenging than it needed to be by such factors might be a little off his A-game, and a referring clinician should probably know if the CTA he ordered isn’t all that reliable for ruling out a PE.

Hedging. I daresay most folks familiar with radiology will know this one. Avoidance of committing to a diagnosis or indeed many declarative statements at all, frequent usage of “weasel words,” and plenty of “cannot exclude” types of statement. Pinning the hedger down as having committed an error is a tricky thing, since the hedger rarely commits to anything at all. Getting back to the golf analogy, it’s debatable whether he really swung his club. Is it a miss if one didn’t really try?

Decreeing. The polar opposite of hedging, and far less common in our field (but all too rife in others, such as politics). No uncertainties are offered, and everything is black and white. Generally seen with those very confident in their abilities (whether or not justifiably), the decreer can be quite popular with referring clinicians since he gives a definitive diagnosis, or exclusion of pathology, without a sense of uncertainty. If/when it is suggested that he erred, the decreer may double down (see below), but he might also own his imperfection. Akin to a golfer whose last swing had visibly-horrible results…but he still poses triumphantly with his club held as high as if he’d gotten an eagle.

Negotiating. Far from the stereotype of the unreachable radiologist sequestered in a hidden reading room, a negotiator’s stock-in-trade is communicating with anyone remotely relevant to an imaging study and documenting it in his report. Often even after the report has been signed off; a proficient negotiator thinks nothing of generating multiple addenda for this purpose. The clinician doubts the diagnosis that was rendered? Addendum plays it down. The patient says their pain was on the other side? Equivocal soft tissue swelling in that area is newly referenced. By the time a reader wades through the maze of addenda, he might have trouble figuring out what the final diagnostic impression was.

Damage control. Close kin to negotiation, this is action taken after one discovers one has been wrong, or stands thusly accused. For instance, an addendum furnished upon hearing results of a patient’s postimaging trip to the OR. Or, after being informed of a peer review issue, plea bargaining that an alleged “major miss” should really be considered a minor one.

Doubling down. Upon being confronted with the possibility of an error, the alleged wrongdoer, often irritated and a bit hastily, reviews his previous work and insists that he was in the right. His vehemence might just cow the individual who detected the error, especially if said individual was at all uncertain. On the other hand, if the error is verified, the wrongdoer may lose “political capital” by so upping the ante…now having failed to recognize his error even when it was pointed out to him.

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