Most of us know other radiologists that fit into the category of second-guesser. Perhaps, you trained or are training under someone like this. Consistently, they debate whether to call a pulmonary nodule or vessel on every other chest x-ray. Or perhaps, when a nurse asks a question about intravenous contrast amounts, they equivocate for what seems like hours. Clinicians don’t know how to proceed. The staff becomes upset. Worst of all, even though these radiologists tend to be very smart, they are targets to lose their job because no one is comfortable with their decisions. You know the type. In today’s post, I will give you some tips to avoid becoming a second-guesser.
Think In Terms Of Highest To Lowest Probabilities
Second-guessers often think about differentials that could be this or that with no differentiation between “this” or “that.” What do I mean? All the different options have the same probability as one another. It is rare for all the differentials to be just as likely as one another in the real world. In less than one out of a hundred cases, there are multiple diagnoses with equal probability of an outcome. So, if it makes sense, stick your neck out a little bit in your conclusion and make your impression the most likely diagnosis. Mention the differential in the comments sections with a description of what is most likely, less likely, and outright unusual. Typically, you will find that you are hemming and hawing much less.
Little Decisions Deserve Little Time; Big Decisions Deserve Big Time
When a nurse walks into the room to ask you how much contrast you should give to a patient with a GFR of 59, you need to decide quickly. Sure, it is somewhat important. We do not want to cause a patient renal failure. But, the difference between giving a patient 100 ccs versus 75 ccs of contrast is unlikely to make much of a difference. This decision is worth no more than 10 seconds of my time in my book.
On the other hand, let’s say you need to decide whether you should biopsy a lesion in the liver. Now, this decision has significant consequences. Biopsies can cause bleeds, infections, and more problems. You really may need to spend some time making this decision. If you have to think through the problem for a while, it makes some sense.
Don’t confuse the little decisions with the big decisions. It goes a long way to preventing you from transforming into a second-guesser.
You Can Miss Em’ Fast Or You Can Miss Em’ Slow
A great radiologist from my residency quoted me the following as he scrolled through a panel of plain films very rapidly, “You can miss em’ fast, or you can miss em’ slow.” I take this statement to heart. Sometimes, when reading cases, there comes the point that looking at a film for a while longer makes no difference in terms of perception. Your first look can be your best look. During the first few milliseconds of looking at a film, your brain unconsciously analyzes the film and can tell if something is off better than staring at an image for hours. Use your gut. Don’t perseverate too long!
Not Every Pixel Is The Same
What do I mean by this? Certain parts of a study are high yield, and others are low yield. For instance, in a patient with breast cancer, metastatic disease likes to go to the bone and liver. So, spend more time looking at these organs. On the other hand, metastatic breast disease does not tend to spread to the spleen. So, use your time accordingly. Spend the appropriate amount of time on each pixel. Pixel selectivity is a tool to prevent you from second-guessing yourself.
If All Else Fails, Make A Decision
Finally, sometimes there are no right or wrong answers. Although not perfect, both directions will allow the clinician to proceed appropriately with a workup instead of perseverating. Sometimes, clinicians need that push to do the right next step for the patient. In this situation, go ahead and make a final decision. You’ll be glad you did!
Avoiding The Second-Guesser Syndrome
Sound advice for avoiding second-guesser syndrome is not emphasized in the radiology curriculum. That’s why I’m here! So, avoid the pitfalls of the second-guesser. Go ahead and create a differential with your most likely diagnosis; utilize the appropriate amount of time for the decision, go with your gut, and spend the right time on each part of the images. You, too, can avoid the second-guesser syndrome and become a decisive radiologist!
