The Goldilocks technique

March 9, 2020

Being persnickety about imaging-technique prefereces could lead to image-quality improvement.

I am, once again, at a coffee-crossroads, looking for the next supplier of my daily jolt. As has happened a number of times in the past, my go-to source stopped carrying my favorite stuff, kicking off a hunt for their replacement.

The Information Age has made this quest easier than it once was. I can now browse Amazon or Google to see what the world has to offer me, rather than searching however many coffee-bearing stores are within reasonable driving distance.

On the other hand, this results in a far greater selection through which I must sift. And, as many coffee drinkers will tell you, individual tastes vary greatly. My ideal is a light roast, sold as whole beans (rather than ground), flavored with chocolate. Emphasis on flavored, since a lot of vendors sell stuff that smells divine but tastes like, well, regular ol’ coffee. As if that isn’t particular enough of me, the method of flavoring is relevant, since some places do it by putting a syrupy coating on the beans that does an amazingly thorough job of gunking up my grinder.

What it all comes down to is that I’m a Goldilocks when it comes to my java. Not so much because it’s got to be “just right,” but because lots of what’s out there is wrong for my purposes. And, again, I’m far from the only one who’s particular about the beverage that starts my day (and re-starts it after lunch).

I’ve also found myself, and more than a few other radiologists, with Goldilocks tendencies when it comes to imaging technique. A difference there is that most of us aren’t owners of our own imaging centers, or are section chiefs who can set policy on how imaging studies are to be done, let alone selectively hire and retain techs who do it the way we like.

I find that many of the chest CTs I read are marred by hypoventilation and/or respiratory motion. PETs I’ve seen in the past decade are variable, but none approach the pristine ones I used to enjoy at an outpatient imaging center before I started doing the telerad thing. And, the arterial duplexes I get-well, let’s just say that a lot of the “peak systolic velocities” I’m given would have gotten the sonographer sent back for more or better scanning in the department where I did my fellowship.

Some of these things are the result of other radiological Goldilockses having their way. (I note that online dictionaries claim the plural of Goldilocks is “Goldilocks,” but that looks weird to me and my spellchecker sees no problem with Goldilockses…even if that sounds like something Gollum would say.)

For instance, it’s a not-uncommon opinion that pulmonary-CTAs are best done with free breathing, since breath-holding, theoretically, diminishes enhancement in the vessels. My two cents would be that most of these CTAs aren’t done with a particular clinical suspicion of PE, but rather as a fishing expedition in the setting of nonspecific signs and symptoms. Thus, I’m more likely to lose valuable diagnostic information with the respiratory motion than I am to possibly catch a subsegmental clot that I otherwise would have missed. Plus, the motion often blurs smaller vessels beyond recognition anyway.

Even putting such “my technical preferences are superior to yours” situations aside, I think the vast majority of cases where a radiological Goldilocks, such as myself, feels forced to eat scalding-hot porridge or sit in an overly-hard chair (i.e., interpret imaging with technique not attuned to my satisfaction) aren’t so much because another Goldilocks-rad had greater pull. It’s because none was exerted. Rather, the imaging is getting done without being up to anyone’s standards in particular, as long as it’s “good enough.”

Under such circumstances, a reading rad might eventually feel emboldened or, possibly, driven to get some changes made. But, that’s tantamount to fighting City Hall. Or, like Goldilocks herself, standing her ground to tell the bears a thing or two about how they ought to prep their porridge and fluff their bedding. This is especially the case if the rad is a relative outsider. A newer hire, for instance, or a telerad or locums providing fleeting or remote coverage.

Not having been in a facility for all that long might actually make an outsider the best source for input as to how things might be done better, since she or he has most recently seen other places’ technique for comparison. However, outsiders tend to have the least amount of influence, or, perhaps, the least motivation to press for change, since they might not be around all that much to live with the improvement.

Whatever the length of a rad’s tenure, probably the biggest obstacle to remediating imaging technique is a sort of inertia. Is there anything I can realistically do to get this improved? Will I just come across as a nitpicker, in the eyes of the techs or other rads? How much time and effort would I need to exert? Aw, forget it-I have so much other stuff on my plate.

I imagine a PACS with a “Goldilocks button” on it. When you see a case that could have been better, press the button, and it gets logged. Maybe there’s an option to enter a brief explanation: Respiratory motion on a follow-up-nodule chest CT, bad patient positioning, etc. The less time it takes rads to use the feature, the more engaged they’ll be by it. Alternatively, it would be easier to implement, but with more clicking and typing legwork for the rads if there were an email address, such as Still, a rad motivated to push for improvement could send a quick message there with case-identifying information and a phrase or two about what was amiss with it.

Periodically, the reported cases would be reviewed. Does anything stand out? A particular tech who has three times as many bad cases as the rest? If so, it’s not easily explained away by patient noncompliance, “poor patient condition,” etc., because, by-and-large, all techs should be seeing roughly the same cross-section of the patient population. Similarly, if you have multiple rads pointing out an issue, it’s not just one perfectionist with a penchant for complaining.