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The Look-alike Game


Playing the game of diagnosing in radiology.

Once upon a time, when my extended family was a little more closely knit, in a geographic sense, and could visit with one another without need of air travel...

…my father had something of a love/hate relationship with a routine that, sooner or later, occurred at every gathering. As he termed it, the “Who looks like who” game, in which participants discussed which members of the fam resembled which other members.

Detractors would point out that the game is a bit repetitive; really, how many times can you meaningfully gab about this one taking after that one? Although I suppose the game might change over time pertaining to younger relatives, since their appearances can morph with growth and maturation.

I’ve not mentioned it specifically to my dad, but it has crossed my mind that, as a diagnostic radiologist, my entire livelihood is now a variant of this game. In a rad’s case, it’s more of a “What looks like what” affair. That is, we look at images, and in our reports proclaim our thoughts as to what sort of pathology (or absence thereof) the pix look like to us.

As with “who looks like who,” our game can be a little repetitive-however big it is, our mental rogue’s gallery of pathology is a finite matter. Looking at a study, we have only so many ready answers to the question of “What does this case look like?” Ideally, just one stands out (a thick appendix with surrounding fat-stranding on a CT for RLQ pain…are you really going to offer a differential?), or none (normal study/no pathology).

The real challenge is when nothing in your rad path repertoire seems to match what you’re looking at, yet what you’re seeing fails to look normal. Suddenly, the question is no longer, “What does this case look like?” but “What could look like this case?” The field of possibilities that must be considered now expands to include the infinite gray zone that dwells beyond the margins of your personal rogue’s gallery, and it’s time to reach for the references (or wiser colleagues).

It would be as if, playing the “Who looks like who?” game, the individual of interest had some unfamiliar features, and someone brought up the notion that, maybe, the individual looked like someone, shall we say, not known to be a member of the family. Awk-warrrrd…but it certainly would make the game more interesting, and much more challenging to “win.”

I definitely get a sense of “uh-oh” when I encounter a “What could look like this?” case, or even when a colleague asks for my input on one. It’s out of my comfort zone, and the chances of my being right about it are a lot lower than if it were a standard “What does this look like?” case. And that’s if I even can come up with some diagnostic possibilities, as opposed to saying the diagnostician equivalent of “Duuuuh, I dunno.”

There is, of course, a way of not even trying: Being purely descriptive in your report, and offering no conclusions whatsoever. I’ve known some rads who do that an awful lot more than others. For the worst offenders, I’ve wondered how on earth they get through a typical workday without having dozens of referring clinicians ringing them up and demanding explanations…and whether their explanations are any more helpful than their reports.

Still, for all the discomfort that those “uh-oh” cases bring, they are a step away from the beaten path, and they do offer great opportunity. If one allows oneself the time to put in the effort of looking things up, enlisting assistance from colleagues, etc., and winds up with a reasonable answer, it can be incredibly intellectually satisfying. Plus, the diagnostic entity in question will henceforth be added to one’s mental catalog of comfortable responses to “What does this case look like?”

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