Some subspecialists make fun of radiologists because our favorite plant is the hedge. (An ancient lousy joke!) To the other extreme, I have found that those radiologists that are over-confident of their diagnoses tend to make the worst radiologists. Many residents don’t realize this, and some emulate these single-minded radiologists because they believe excess confidence helps patients and physicians. But, when they get out into practice, they recognize the error of their ways. And, quickly, they reverse course. So, let’s go through why that is the case before you may become one of those casualties. And then, I will provide a simple solution to get your point across without sticking to one foregone conclusion.
Why Radiologists Cannot Be Over-confident
Zebras Do Occur (Even For Over-Confident Radiologists!)
Of course, not all of our diagnoses have simple outcomes. For every 1000 peri-tonsillar abscesses, there are a small number of infected squamous cell carcinomas. And, there is also a smattering of even rarer birds that happen from time to time. I’ve been around a bit to see a lot (although not everything!) And, I know enough not just to hang my hat on my one beloved diagnosis.
All Of Us Sometimes Have Blinders On
Just like other clinicians, histories can sway us. If your ordering doctor constantly pushes toward one ineffable diagnosis, you, as a radiologist, are most likely to think the same. And that is the moment when you need your radiology cap on your head. Those intense pressures can easily lead you down the wrong road. At this point, we need to step back and reanalyze the situation and think about all the possibilities, not just the most likely.
The Legal System Is Not Forgiving
What do you think about when you see a bit of bowel wall thickening in a small bowel loop with no pneumatosis, free air, free fluid, focal fluid collections, or extraluminal contrast. Usually, it is infectious or inflammatory enteritis. But every once in a while, it turns out to be something much more malicious. Perhaps, the earliest sign of ischemia? I have seen multiple radiologists not mention the word ischemia somewhere in their dictation. And, the outcome for the physician (and sometimes the patient) has not necessarily turned out so well. The legal system does not allow for finite diagnoses, especially when one of those more unusual diagnoses can lead to a not-so-great result!
Potential Bad Patient Outcomes
And, most importantly, like in the ischemic small bowel example above, when we limit our differential diagnosis, we can also affect patient outcomes. Some clinicians will keep the alternative diagnoses in the back of their minds or will prophylactically treat for these entities even though it may not be your first suspicion. And, even though you may put these diagnoses third, fourth, or fifth on the list, it doesn’t mean it shouldn’t be in the dictation. We have to allow our clinicians to be aware of the unforeseen to prevent these bad outcomes.
How To Solve The Problem Without Being Too Hedgy
Given all the pitfalls of the over-confident radiologist, we usually should not come down too hard on one diagnosis. Instead, we have to give more than one option to clinicians because multiple possibilities exist. Yet, it is effortless for radiologists to get bogged down in a list, which also does not help the clinician. Suppose you come up with a list of differentials on a chest film of ARDS, pneumonia, or pulmonary edema; how does that help the clinician? How can you escape this hedge-like conundrum?
Very simple. Ensure your reports talk about the diseases and a list of probabilities to go with the diagnosis. For instance, if you are leaning toward the diagnosis of pneumonia, you can say that the study is most consistent with pneumonia because of the fever and the multifocal pattern. But, make sure to say that other etiologies are less likely, how much less possible, and why. This technique allows us to guide the clinician toward the most likely diagnosis.
Instead Of Making The Mistake Of Becoming An Over-Confident Radiologist, Master Probability!
Radiologists have lots of diagnoses from which to choose. And, any one of these, albeit unlikely, can come true. So, we can’t afford to become overconfident and make the mistake of picking just one. Therefore, radiologists need to become circumspect and know the likelihood of outcomes. Our role is to guide our fellow physician colleagues. Thus, to become excellent radiologists, we should not adopt the tact of overconfidence. Instead, we need to become masters of managing probability!
