0:01

Okay, so read fewer cases.

0:03

Um, number two,

0:05

strategize against making misses based on

0:09

your previous misses.

0:12

Um, this is an interesting, um, example of

0:16

how we as radiologists are able to overlook something

0:20

because of what we call satisfaction of search.

0:23

So in this specific CT scan, people were told

0:26

to find the cancer.

0:29

And, um, naturally you see that there is a mass here

0:33

in the posterior aspect of the right lung,

0:36

and people focus on that.

0:38

Um, it turned out that 83%

0:41

of radiologists did not miss this.

0:44

What they missed was the gorilla

0:47

that had been superimposed on the sup, you know,

0:50

the anterior portion of the left lung

0:53

and never commented about it.

0:55

So that type of satisfaction of search miss is one

0:59

of the ones that we will strategize against.

1:03

Okay, so strategize for detection misses.

1:06

Um, in some ways this is a benefit of people

1:10

who use templates to create sort of a checklist

1:15

for what they should be looking for on scans

1:19

or plain films, et cetera.

1:21

So they have little cues in their templates

1:25

that make them look at their previously

1:28

discovered blind spots.

1:31

So if you keep a record of your missed case locations

1:34

and notice that there's a trend

1:35

that you are missing cases in the right upper lung,

1:38

you might wanna put a prompt in your template

1:44

images of the right upper lung show,

1:47

and then you have to fill it in

1:48

and you're forced to kind of look in your blind spot.

1:52

Um, it's important to have a curve serve a habitual way

1:57

that you look at studies.

1:59

Having a strategy for looking at individual images,

2:04

be it plain films or MRI cts, ultrasound et cetera, is,

2:08

is useful as well.

2:09

And in some cases, people will specifically

2:15

refer to the periphery of an image as opposed

2:17

to the central area

2:18

where you're generally focusing your eyes on the

2:22

center of the image.

2:24

So create templates that eliminate your weakness.

2:26

So one of the things that I had experienced was that

2:31

there were a couple of cases of parotid masses

2:34

that were only seen on a sagittal t one of the brain,

2:39

um, because of the field of view.

2:42

And I recognized that I was

2:45

not looking at the parotid glands on a head MRI scan

2:50

with MR with, uh, sagal images.

2:53

So adding in the parotid gland images show blank

2:57

and I have to fill it in, forces me

3:00

to look at those ate glands.

3:02

Or if you've missed a couple of Chiari malformations

3:05

with cerebellar tonsils below the frame of magnum,

3:08

you can add in that, into that template.

3:11

For example, um, the CARES classification is one

3:14

of the classifications that looks at the depth

3:17

of the cribriform plate and crita gall region.

3:20

And you can add that in if you have failed to look at that

3:24

or report on that for your cy nasal surgeons.

3:28

For people who are more inclined to look at,

3:33

uh, for example, kidney cyst, you can make the template

3:38

give you a prompt for the classification, uh, the bosniac

3:44

criteria in the report,

3:45

and then say, based on these, this classification,

3:49

the right renal cyst is classified as type blank.

3:52

And that way you don't have to remember it

3:54

or look it up, it's right there in your template.

3:57

So that's some ways that we can mitigate those types of,

4:02

uh, errors to strategize against misses satisfaction

4:06

of search matches, which is the one I I showed referred

4:09

to you with regard to that, uh, gorilla.

4:12

Um, they, that is sort of a common

4:17

way that radiologists make mistakes.

4:19

They find the lung cancer, they find the, the, the,

4:25

the, um, mediastinal lymphadenopathy associated with

4:28

that cancer, but they may miss the, you know,

4:33

remote fracture of the rib.

4:35

Now it might not be important at all,

4:36

but it's still considered a minor, uh, miss for example,

4:40

because they think that they've satisfied with all

4:44

of the findings and they may lose their focus.

4:47

So as best as you can, you gotta maintain your focus, your,

4:51

your template will help you to continue to look at the ribs,

4:54

to continue to look at the slovic

4:56

or fossa to continue to look at the trachea on that.

4:59

Uh, chest x-ray, every case should be treated like

5:03

Marfan's disease with multiple potholes.

5:06

You know, Marfans, they can have

5:07

so many different pathologies in the head

5:10

and neck region with lots of problems with, uh, teeth

5:14

and mandible and with pulmonary issues, as well

5:17

as having issues with the vasculature.

5:21

So every case potentially could have multiple abnormalities.

5:25

So I wanna just talk a little bit about my

5:27

vestibular schwannoma, miss.

5:29

So I was, uh, one of the cases that was a pretty gross miss

5:33

by me was a patient who had fibromuscular dysplasia

5:38

and had prior aneurysms

5:41

and dissections who came into the emergency room complaining

5:45

of dizziness and ataxia.

5:48

And I looked at the case

5:51

and I was so engrossed with the blood vessels

5:53

and looking at the prior ones to see

5:55

where the vertebral artery

5:56

Dissection had changed or not.

5:59

And it was A-C-T-A-C-T-P.

6:01

So there were thousands of images for the CT angiogram,

6:05

thousands of images for the CT perfusion study.

6:08

And, um, in the end of all of this,

6:13

I missed a small vestibular schwannoma

6:16

that could be seen in the internal auditory canal.

6:20

And it was a satisfaction of search.

6:22

I just had, I was exhausted with looking at all

6:25

of the different blood vessels and looking at the perfusion

6:28

'cause there were some perfusion abnormalities

6:30

because of the dissections.

6:32

And, um, I lost my focus

6:34

and missed the vestibular schwannoma.

6:36

The patient came back six months later

6:39

and was complaining of the same symptoms, got an MRI scan,

6:42

which showed the vestibular schwannoma.

6:44

Unfortunately, it had grown about 0.2 centimeters

6:49

and ultimately the patient went on to, uh, surgery,

6:53

but she actually contacted me, I'm not sure exactly

6:57

how she was able to get my email,

7:00

but said to me when the MRI came became positive, she said,

7:04

would you mind re-looking at your C-T-A-C-T-P

7:08

that I had six months ago

7:09

and tell me whether my vestibular schwannoma was there?

7:14

So quick phone call to risk mitigation services at Hopkins,

7:19

uh, because it was there anyway, uh, satisfaction of search.

7:23

So the templates may help you with reducing those types of,

7:27

um, errors.

7:30

So try to maintain a high concentration.

7:33

Remember, a patient with one abnormality is actually more

7:35

likely to have a second

7:38

abnormality than a patient without an abnormality.

7:40

So this is what we call inattentional blindness,

7:42

where you no longer have maintain your attention.

7:46

The opposite effect occurs with low prevalence targets.

7:49

You're more likely to dismiss a finding if you think

7:52

that something is rare.

7:53

So, for example, cervical spine screening in the ed,

7:58

you read, you know, 200 cases for one positive case.

8:02

When that one positive case comes, comes in.

8:04

You've seen so much DJD that you may ascribe

8:09

that little linear finding to, uh,

8:12

irregularity from degenerative facet joint disease rather

8:15

than a facet fracture.

8:17

Satisfaction of search.