0:00

So here's one where I would say do as I say, not as I do.

0:06

Um, read the prior reports of your colleagues

0:11

and read those prior studies.

0:13

Having comparisons is really useful.

0:17

I'm very good at reading the prior images

0:20

and calling up images from, you know,

0:23

remote packs, et cetera.

0:24

Where I don't spend a lot of time is reading my colleagues

0:28

or other people's reports.

0:30

That's a mistake. And I've found that, you know,

0:32

my confidence in myself in reading the prior study is

0:37

not necessarily well-founded.

0:39

Those people who are reading the prior studies, that's

0:42

what they're focusing on.

0:43

I'm just sort of scouting the prior study

0:45

to look for any changes.

0:47

Um, so there, there are a lot of cases where

0:51

incidental findings that were not related to what I'm, what,

0:54

what the main issue is we're found by the primary reader.

0:58

On the prior study that I don't recall,

1:00

so I got a call from Justin MacArthur, the Department

1:03

of Neurology, uh, chief, who is one of the PA people

1:06

who has an interest in multiple sclerosis.

1:09

And I was reading a patient case who had

1:13

multiple white matter lesions.

1:15

It was brain, cervical, and thoracic spine.

1:17

Some of them were enhancing, some

1:18

of them were not enhancing, there were black holes,

1:20

there were all kinds of issues with volume loss, et cetera.

1:24

And I read the Ms. Case

1:25

and, you know, reported on some new MS plaques.

1:29

And, uh, I get a, an email from Justin.

1:32

Um, what about the meningioma? Like, what do you mean?

1:36

What about the meningioma?

1:38

Uh, your colleague,

1:40

NAFI iGen six months ago called a para para

1:43

sagittal meningioma.

1:45

Did you see that? And this is the old satisfaction

1:49

of search, et cetera.

1:50

Um, and I went back

1:52

and of course there's some meningioma there.

1:54

And, um, I said to him, well, why didn't you tell me

1:58

that there was men geo in your history?

2:00

Your history was follow up ms, not follow up MS.

2:03

And meningioma. And he said, do I really have to do that?

2:06

So, um, nafis report, if had I read it would have,

2:11

you know, been very useful.

2:13

I did compare with the prior study,

2:14

but I was looking for MS bucks,

2:16

not necessarily a meningioma.

2:18

So, um, look at the prior images, look at the prior reports

2:22

and look at the electronic medical record.

2:24

And not an ounce of clinical history.

2:26

Sometimes is worth a pound

2:28

of radiology gibberish in a differential diagnosis.

2:31

You know, if you know the patient has known multiple

2:34

sclerosis that's been previously worked up, you don't have

2:37

to talk about all the different things

2:39

that might cause white matter disease including, you know,

2:42

vasculitis and sarcoidosis and migraines, et cetera.

2:45

So look at the, uh, electronic medical record.

2:48

Direct your reading. There is a benefit

2:50

of having multiple readers look at the case.

2:52

So, you know, over the course of time, you know,

2:56

with four different people reading these MS PAC

2:59

Studies, one of us would've found that meningo.

3:01

And it happened to be Nagen, who by the way, is a fantastic

3:06

radiologist and, um, doesn't miss very many things at all.

3:09

So the prior history sometimes is helpful.

3:12

Don't be Dave, Dave,

3:15

don't be overconfident in your own reads.

3:18

Look at the prior reports

3:20

and see what your colleagues have recommended.

3:25

So, um, comparison is value,

3:30

valuable in and of itself.

3:32

Value your peers, you know, you know

3:34

that they're good from your peer review.

3:36

Don't overestimate your own skill.

3:41

Here was a case of a patient who was read

3:43

as multiple sclerosis, has light,

3:47

nice white matter plaques, et cetera,

3:49

at the cosal septal interface.

3:51

And, um, one of my colleagues read this

3:54

as demonstrating periaqueductal high signal intensity

3:58

and just ascribed it to multiple sclerosis.

4:01

Um, I looked at the case

4:03

and said, Hmm, I wonder whether the patient has thiamine

4:06

deficiency and could have, you know, a warnick appearance.

4:10

And sure enough, this patient not only had ms,

4:13

but this patient had had bariatric surgery

4:17

for two months previously

4:19

and had been having much lower intake

4:24

of food in general and thiamine in specific.

4:28

And, uh, fortunately this patient, um,

4:31

received thiamine replacement.

4:33

So look at your prior reports and everything,

4:35

but also have a little bit of a skepticism.

4:37

We're being sued by the big bad wolf.

4:39

Apparently he injured his back on our property while trying

4:43

to blow the house in.

4:45

So the three little pigs.