In an ideal world, radiologists, in particular, would like to get all the cases right all the time. But, in reality, we know that can never happen since radiologists are people. And, we deal with imperfect technologies. Some findings will go undetected, and others misinterpreted. But that is the way of the world.
So what can we control? Well, we can adjust our sensitivities. Increasing our sensitivity allows us to make more findings at the expense of causing all our patients to receive too many additional tests. Subsequently, they would receive elevated doses of radiation and too many biopsies.
Decreasing our sensitivity sets us up for missing findings. These same misses can lead radiologists down the path of patient care issues and lawsuits. So, we continually set our internal thermometers to call cases toward either overcalling or under calling to get to that perfect mean. And, radiology residents must learn to do the same.
How Do We Adjust Our Internal Thresholds?
So, what causes us to change our sensitivities and become overcallers? Well, have you had a recent lawsuit or a bad mistake? You probably will overcall a bit for fear of missing findings. Do you have a large population with healthy hearts and read cardiac nucs. You probably are under calling a patient’s cardiac disease, knowing that most patients have none.
Additionally, we are continually tweaking our internal standards all the time. Should we call that skin fold over the chest as a pneumothorax? Or, is there a trace subarachnoid hemorrhage near the calvarial fracture site? These are the questions that we face daily. And how we choose to answer them affects the patient care we deliver.
What About Radiology Residents Versus Attendings?
Moreover, radiologists and radiology residents practice in two alternative universes. And, their pitfalls differ substantially. To that point, what can dramatically affect an attending’s care can barely impact a resident and vice versa. For instance, chronically overcalling lung nodules on chest films as an attending can anger your referrers. In a worst-case scenario, a practice may even decide to fire overcallers over the issue.
On the other hand, it may be desirable to overcall those same nodules as a resident. Your attending may want you to call the finding to alert them to whether it should make a clinical difference. She can always discard it in the final report if it does not change management.
So, Where Should Residents Lie Within The Spectrum During Residency?
In general, under calling as a resident, can be particularly dangerous for many reasons. First and foremost, residents have a lack of experience upon which to rely. After your 10,000th case of pneumonia, you will have probably have seen enough to almost instinctually know what most types of pneumonia look like on a chest film. Residents don’t have that background on which to make a judgment. So, when you don’t call pneumonia, you are more likely going to miss the signs of one.
Second, the hazards of under calling far outweigh the benefits of overcalling. If you are on an overnight shift and you are not sure whether your patient has a bleed, you can cause much more damage by sending the patient home with a bleed. The consequences of keeping the patient in the hospital with that more sensitive call are much less devastating. This philosophy goes for most serious disease entities.
And then finally, you make your attendings happier when you overcall rather than under call. I would much rather see a resident make all the findings of equivocal tiny nodules and questionable hepatic cysts. Although part of the spectrum as overcallers, these residents make findings that can help me to pick up lesions I may miss as a radiology attending. A pair of second overly sensitive eyes can be an excellent accessory screening tool to ensure that the radiologist does not miss the findings as well.
Chronic Overcalling Can Lead To A Difficult Attending Transition
But, this chronic overcalling can lead to a problem at your first attending gig. You have accustomed yourself to overcalling findings as a resident. Now, as radiology faculty, that same sensitivity point may not work well to allow you to flourish in your career. But, you have worked at this threshold level for a while. Not so easy. Habits die hard. We see this issue all the time with new radiologists.
What’s The Point Of This Conversation About Overcallers?
Well, residents need to be aware of their thresholds for making findings. Yes, it is worth it to start as overcallers based on less experience and the consequences of missing critical diagnoses. But, be wary about maintaining the same thresholds as you move along in your career. Be mindful of slowly trying to increase your limits for detection over time using your increasing experience and knowledge. The goal is to get you closer to the perfect sensitivity in an endless asymptotic curve. So, be ready to adjust your approach as an attending. It may save your career!
