Musings About Elections, Cheating and 'Pure' Radiology

Is due consideration of patient history, demographics, and previous imaging essential or a cheater’s crutch when assessing new imaging?

With elections being just around the corner, I recall a particular episode of the Britcom Blackadder that took a swipe at politics. Asked how he plans to win an election, the titular character replies, "Firstly, we shall fight this campaign on issues, not personalities. Secondly, we shall be the only fresh thing on the menu. And thirdly, of course, we'll cheat."

Cheating is a funny concept. The dictionary definition is pretty clear-cut as is the mindset of one who believes he or she, or someone the person supports, has been cheated out of something. Under such circumstances, cheating is considered a pretty lowdown, no-good way to behave. Of course, if you ask the accused cheater, he or she will give you a very different accounting.

However, one of the weird facets of cheating is that pretty much everyone would agree that, under the right circumstances, it can be the proper thing to do. If that statement sticks in your craw, you probably haven't let your imagination sufficiently loose.

For instance, suppose a madman has a gun to a hostage's head, and tells you to flip a coin. If you get heads, he will shoot the victim dead. But if you get tails, he will drop the gun and allow himself to be taken into custody. Now you get to flip the coin and tell him the result. (For the purpose of this scenario, consider it a given that, as result of his madness, he will unquestioningly abide by your answer).

I'm just going to say it. If you get heads and play fair, causing the hostage to die, there is something very wrong with you. The right thing to do is cheat and say that it came up tails.

One could apply this notion to elections as well. Suppose you knew with certainty that the modern-day equivalent of Hitler was about to be voted into power and was on the precipice of doing nightmarishly bad things. Perhaps you and some of your allies some allies have the ability to cheat and tip the outcome of the vote so Hitler loses. Many, I daresay most, people would consider it a moral obligation to do so.

In my life as a radiologist, I might be considered an unabashed cheater. I use every trick I can think of to do the best diagnostic job I possibly can.

A lot of cheaters, myself included, don't admit, or even necessarily consider that what they do is cheating. When I cheat, the rules I break are the ones that were taught in residency about how to practice what I'll call "pure" radiology. They are good rules for learning and to pass on to trainees of your own if you stay in an academic setting. They center on the idea of interpreting images in the absence of any other information.

Again, this is a good thing for someone learning to practice radiology: You want to be able to extract as much diagnostic info as possible from the pictures, without leaning on crutches like clinical history, results of previous imaging studies, or patient demographics. Any of these may bias the interpreter and cause him or her to favor one diagnostic possibility or exclude others. Also, as you might have noticed from previous blogs of mine, such ancillary information, when present, can be dangerously misleading.

In case conferences during my training, someone projecting a film (yes, we were still using those for the most part) would usually make a point of covering the patient gender and age. If the resident were to ask about this info, the answer would be dismissive. You don't need to know that, and you had better not ask such questions when you go to Louisville because it suggests you are stuck and unable to say anything useful about the case as is.

(If you're asking what Louisville has to do with any of this, clearly you're not a radiologist of a certain age.)

A rad resident playing by the rules might say things like "If this was a young female patient, I'd be thinking about diagnosis X. But if this is an elderly male, I might be thinking Y." In addition to getting his or her evidence purely from the images, the trainee would also get that much more educational value from the experience, talking about two or more hypothetical patients from a single study.

It has been a while since I was in training, and I have nothing to do with teaching future radiologists. Playing by those rules might have a certain purity to them, but everything I do is in the name of giving the best diagnostic results I can.

I look at the patient demographics up front. I sift through whatever documentation I can get about the patient, including notes jotted down by the tech and prior imaging-reports. They will almost always tell me way more than whatever the referrer (or clerk) wrote on the "reason for exam."

Outside of a super STAT situation like major trauma or a possible stroke, I don't waste anybody's time first looking through the current images in the name of not "biasing" myself with any other valuable info I can get. To my way of thinking, that's about as helpful as reading cases with one eye open. “Hey, watch me show how good I am by reading this case with extra self-imposed obstacles!"

This isn't the Radiology Olympics (bonus points for anybody reading this blog long enough to remember that invention of mine). We're not competing for "love of the game" and eschewing unfair advantages against other rad competitors. I guarantee that patients and referrers would far more appreciate their rads using every trick they can think of to do the best job. Speed is another consideration. The 10th patient on your worklist probably wouldn't appreciate the idea that his or her interpretation was being held up because the previous nine cases were being treated as some sort of game.