Happy Eyes

May 25, 2017
Eric Postal, MD

Seeing one answer to a problem might make you less likely to look for another, less obvious one.

The first time I remember hearing radiologists talking about “happy eyes,” I was already in fellowship. The term made me envision the squinty-ocular look that accompanied a big, genuine smile…which was not what it was supposed to reference. If I’d heard the term earlier in my training, it hadn’t registered. I had definitely encountered the more traditional phrase referencing the same phenomenon: “Satisfaction of search.” Maybe even in my days with psychology, before med school, let alone rad-residency. At the risk of telling the reader what most in our field probably know, these terms reference a potential pitfall awaiting anyone who’s looking for something-an abnormality on an imaging-study, in our case, but more broadly a solution for a problem. Put simply, once you’ve come up with an answer to your query, you’re less likely to go on searching for another. Even if you do, it’ll probably be a less-intense effort. In many circumstances, this is adaptive, if not common sense. After you’ve found your missing car keys, for instance, you hopefully don’t go on searching for them. If your computer isn’t functioning properly, and you tinker with the hardware until it works normally again, you probably won’t continue to look for problems. Even in healthcare-radiology included-we’re taught that, when one diagnosis will account for all abnormal signs/symptoms, it’s better than theorizing two or more separate pathological conditions. Not only is simplicity aesthetically pleasing, the probability-math favors it. All that being said, it’s far from rare for there to be more than one type of pathology in a given patient…and, especially when we’re working with advanced imaging that covers far more of the anatomy than the specific focus of clinical suspicion, there’s plenty of potential to discover occult conditions lurking behind the woodwork.  Being satisfied that you’ve answered the clinical question…your eyes being “happy” that they have found the metaphorical smoking  gun that brought the patient to the ER...can impair your ability to identify something else that might bring them to the ER next week, if left undetected. Or the oncology-clinic, next year. In an odd way-and I pray that the clinicians who refer patients for imaging in the facilities I cover never read this and take direction from it-my susceptibility to “happy eyes” has diminished over the years as I have been provided less and less reliable patient histories.  That is, if I am told that an X-ray of the hand is following minor trauma to the base of the thumb, and I find a fracture there, my scrutiny of the fifth ungual tuft is probably going to be less than if, as is far more common, I get the same set of images with a history of “pain.” The non-history I get in the latter instance might just be what makes me take notice of the subtle glomus tumor lurking there.