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Did you ever pay close attention to clinicians looking at an imaging study, say a radiograph of the chest, and wonder what they were thinking about? Some just seem to be standing in front of the viewbox staring, waiting for the answer to fall at their feet. It is certainly not an active process. They don't seem to be fully engaged. There is no gesticulating or tracing of fingers across the image, no bending forward to take a closer look. No mumbling under the breath or muttering about things they may have seen. No stroking of the chin. They just stand there motionless, blankly staring at the image. It's enough to make you wonder what the devil is going through their minds. Maybe they expect the meaning of the image to mystically appear as payment for their expenditure of time in front of the viewbox. After all, they are important individuals and their time is valuable.
The interpretation of imaging examinations is not intuitive. The gleaning of meaningful information from imaging studies requires knowledge of the imaging technique, an understanding of anatomy and its appearance as projected by the imaging technique, familiarity with disease processes that could be encountered, and awareness of the imaging findings that might accompany each of these diseases. You have to know what you are looking at. You have to know where to look and what to look for. In the words of the late, great radiologist, Dr. L. Henry Garland, "You see what you look for and recognize that which you know" (Garland LH, personal communication).
The interpretation of imaging is neither passive nor easy. It just looks easy. Sitting in a darkened room and looking at films on a viewbox or peering at images on a monitor—what could be easier than that? Outsiders can get the wrong impression.
The interpretation of images requires concentration. And it isn't always easy to concentrate. You are bombarded by distractions. There are telephone calls, consultations with referring physicians, questions by technologists regarding upcoming or ongoing procedures that must be answered, and all the other routine business of the day that demands your attention. When attempting to read out the board, you'll find these interruptions make it hard to stay focused. The mind tends to wander.
How to stay focused? Establish a dialogue with yourself to maintain your concentration. Ask yourself questions about the case in question. What am I looking at? What should I be looking for? And then look for it. What am I likely to miss if I am not careful? And then look for that. And what else should I look for now that I have noted this finding? And then look for that too! Keep talking and keep looking until you feel certain that you have made a thorough assessment of the case. Make the effort to stay focused; otherwise, you are liable to find yourself acting like one of those clinicians described above: staring vacantly at the viewbox while thinking of other things.
You can try to impose some systematic method of viewing images, like trying to cover the study in a specific geometric manner, say by starting in the upper left hand corner of the image and then proceeding in some set pattern over the remainder of the image. But this is difficult. Geometric patterns of search just don't work for me. On initial viewing, I find that my eye is drawn to one or more findings for some reason or other, not always explicable, and that I must resolve these as normal, abnormal, artifactual, or even nonexistent, before I can comfortably proceed to look at the remainder of the image. Sometimes I get stuck on one finding or other for what seems like forever before deciding on its etiology and importance, and then I forget to look at the remainder of the examination. This is not good. There is always the potential for errors of omission. Once satisfied, your attention may turn to the next case.
We could all use a gentle reminder to keep looking.
These observations are brought to mind by an interesting and informative article in this issue of the AJR by Ashman, Yu, and Wolfman, "Satisfaction of Search in Osteoradiology" [1]. "Satisfaction of search" refers to the fact that the detection of one radiographic abnormality may interfere with the detection of other abnormalities on that examination. In other words, in viewing radiographs there is a tendency to become satisfied after identifying the first abnormality and that may lead to a failure to search for additional findings. Intuitively we are aware that this tendency is a likely source of diagnostic errors. Now our intuition has been scientifically evaluated and found to be true.
The principle of satisfaction of search is not limited to imaging of the musculoskeletal system. Satisfaction of search is a general principle germane to the interpretation of all forms of imaging. Therefore, a perusal of the article by these researchers would profit everyone involved in diagnostic imaging.
Read, mark, and inwardly digest. Whether you are a generalist or a subspecialist, the article by Ashman et al. [1] is bound to do you good!
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