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Batheja V, Javan R, Awan OA. Understanding and Embracing Error in Diagnostic Radiology. Acad Radiol 2024:S1076-6332(24)00457-4. [PMID: 39155156 DOI: 10.1016/j.acra.2024.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2024] [Accepted: 07/15/2024] [Indexed: 08/20/2024]
Affiliation(s)
- Vivek Batheja
- George Washington School of Medicine and Health Sciences, Washington DC (V.B.)
| | - Ramin Javan
- George Washington University Hospital, Washington, DC (R.J.)
| | - Omer A Awan
- University of Maryland School of Medicine, 655 W Baltimore Street, Baltimore, MD 21201 (O.A.A.).
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Dang TH, Rieu-Werden ML, Kobrin SC, Tiro JA, Werner C, Lykken JM, Chubak J, Atlas SJ, Higashi RT, Lee SC, Haas JS, Skinner CS, Silver MI, Feldman S. Association Between Clinician Confidence and Making Guideline-Recommended Decisions in the Management of Abnormal Cervical Cancer Screening Results. J Gen Intern Med 2024:10.1007/s11606-024-08943-z. [PMID: 39060782 DOI: 10.1007/s11606-024-08943-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 07/05/2024] [Indexed: 07/28/2024]
Abstract
BACKGROUND Guidelines for managing abnormal cervical cancer screening results are complex and adherence is challenging for clinicians. Previous studies have identified gaps in knowledge as a possible cause; few have explored the confidence clinicians have in their management decisions. Confidence in decision-making may influence management practices, particularly when guidelines are complex and evolving. OBJECTIVE Assess whether confidence in decision-making is associated with making guideline-concordant recommendations for abnormal cervical cancer screening results. DESIGN A clinician survey used vignettes to ask clinicians to make a management recommendation for different abnormal results and rate their level of confidence in their response. PARTICIPANTS Physicians and advanced practice providers (APPs) at three diverse health systems in Washington, Texas, and Massachusetts. MAIN MEASURES Correct response to each vignette based on either the 2012 or 2019 American Colposcopy and Cervical Pathology (ASCCP) management guidelines. KEY RESULTS In total, 501 clinicians completed the survey between October and December 2020 (response rate 53.7%). Overall, most clinicians made guideline-recommended management decisions for two vignettes (73.2 and 73.7%), but fewer were confident in their selection (48.3% and 46.6%, respectively). Clinicians who reported high levels of confidence were more often correct than those who reported lower levels of confidence (85.8% vs. 62.2% and 87.5% vs. 60.7%, both p<0.001). After adjusting for clinician and practice characteristics, confidence remained significantly associated with selecting the correct answer. CONCLUSIONS Clinician confidence in management decisions for abnormal cervical cancer screening results was significantly associated with knowing guideline-concordant recommendations. Given the complexity of cervical cancer management guidelines, solutions to improve clinician confidence in decision-making are needed.
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Affiliation(s)
- Tin H Dang
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Meghan L Rieu-Werden
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sarah C Kobrin
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, USA
| | - Jasmin A Tiro
- Department of Public Health Sciences, University of Chicago Biological Sciences Division, Chicago, IL, USA
| | - Claudia Werner
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Parkland Health and Hospital System, Dallas, TX, USA
| | - Jacquelyn M Lykken
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jessica Chubak
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Steven J Atlas
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Robin T Higashi
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Simon C Lee
- Department of Population Health, Medical Center, University of Kansas, Kansas City, KS, USA
| | - Jennifer S Haas
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Celette Sugg Skinner
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Harold C Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Michelle I Silver
- Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Sarah Feldman
- Division of Gynecologic Oncology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
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Irwin SP, Ryan JB, Baluyot RF, Solivan-Ortiz AM, Schindler DK, Graver JD, Vandewalle KS. Assessing the Use of Radiographs Alone to Determine Air Force Dental Readiness Classification. Mil Med 2024:usae315. [PMID: 38894664 DOI: 10.1093/milmed/usae315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 05/31/2024] [Accepted: 06/05/2024] [Indexed: 06/21/2024] Open
Abstract
INTRODUCTION The Air Force Dental Service is responsible for ensuring that airmen are dentally ready to support military operations worldwide by delivering top-tier dental care. As the military healthcare landscape undergoes significant changes, the Air Force Dental Service has explored innovative approaches to dental care delivery. One consideration involves the potential use of radiographs as the primary tool for assessing service members' dental conditions, specifically focusing on identifying nondeployable conditions and periodontal health. MATERIALS AND METHODS Providers who previously participated as examiners in the 2018 Air Force Recruit Oral Health Study were recruited to re-evaluate randomly selected de-identified records, this time making assessments exclusively based on radiographs. Their evaluations included Dental Readiness Classification (DRC) determinations, total caries counts, and Periodontal Screening and Recording (PSR) index scores, providers also rated their confidence in these conclusions using a 5-point Likert scale. The study then computed sensitivity and specificity to assess the diagnostic performance of providers using radiographs only compared to the original study results that use the gold standard of radiographs with a clinical examination. RESULTS Providers exceled at ruling out most DRC 3 conditions, with specificities surpassing 70%. Positively identifying those with DRC 3, particularly radiographically identifying periodontal conditions posed challenges with computed sensitivity rates as low as 8%. Discrepancies in PSR scores also accentuated limitations in relying solely on radiographs, where provider's radiographically determined PSR scores that matched less than one third of the time. In general, providers had low to very low confidence in their assessments. CONCLUSIONS The study strongly cautions against relying solely on radiographs for determining the dental health of U.S. Air Force personnel. While providers effectively ruled out the absence of certain conditions, the challenge of positively identifying DRC 3 conditions poses significant risks to oral health if such a workflow was utilized. Particularly, the high probability of false negatives would be detrimental to the operational readiness of military personnel. Therefore, results support the continued use of radiographic and clinical examinations for comprehensive dental exams.
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Affiliation(s)
- Scott P Irwin
- Dental Research and Consultation Service, U.S. Army Institute of Surgical Research, JBSA-Fort Sam Houston, TX 78234, USA
| | - J Brett Ryan
- Dental Research and Consultation Service, U.S. Army Institute of Surgical Research, JBSA-Fort Sam Houston, TX 78234, USA
| | - Rondre F Baluyot
- Minot AFB Dental Clinic, Minot 5th AFB Medical Group, Minot AFB, ND 58704, USA
| | | | - David K Schindler
- Dental Research and Consultation Service, U.S. Army Institute of Surgical Research, JBSA-Fort Sam Houston, TX 78234, USA
| | - Jay D Graver
- Uniformed Services University Postgraduate Dental College, JBSA-Fort Sam Houston, TX 78234, USA
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Ma D, Badve C, Sun JEP, Hu S, Wang X, Chen Y, Nayate A, Wien M, Martin D, Singer LT, Durieux JC, Flask C, Costello DW. Motion Robust MR Fingerprinting Scan to Image Neonates With Prenatal Opioid Exposure. J Magn Reson Imaging 2024; 59:1758-1768. [PMID: 37515516 PMCID: PMC10823040 DOI: 10.1002/jmri.28907] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 07/04/2023] [Accepted: 07/05/2023] [Indexed: 07/31/2023] Open
Abstract
PURPOSE To explore whether MR fingerprinting (MRF) scans provide motion-robust and quantitative brain tissue measurements for non-sedated infants with prenatal opioid exposure (POE). STUDY TYPE Prospective. POPULATION 13 infants with POE (3 male; 12 newborns (age 7-65 days) and 1 infant aged 9-months). FIELD STRENGTH/SEQUENCE 3T, 3D T1-weighted MPRAGE, 3D T2-weighted TSE and MRF sequences. ASSESSMENT The image quality of MRF and MRI was assessed in a fully crossed, multiple-reader, multiple-case study. Sixteen image quality features in three types-image artifacts, structure and myelination visualization-were ranked by four neuroradiologists (8, 7, 5, and 8 years of experience respectively), using a 3-point scale. MRF T1 and T2 values in 8 white matter brain regions were compared between babies younger than 1 month and babies between 1 and 2 months. STATISTICAL TESTS Generalized estimating equations model to test the significance of differences of regional T1 and T2 values of babies under 1 month and those older. MRI and MRF image quality was assessed using Gwet's second order auto-correlation coefficient (AC2) with confidence levels. The Cochran-Mantel-Haenszel test was used to assess the difference in proportions between MRF and MRI for all features and stratified by the type of features. A P value <0.05 was considered statistically significant. RESULTS The MRF of two infants were excluded in T1 and T2 value analysis due to severe motion artifact but were included in the image quality assessment. In infants under 1 month of age (N = 6), the T1 and T2 values were significantly higher compared to those between 1 and 2 months of age (N = 4). MRF images showed significantly higher image quality ratings in all three feature types compared to MRI images. CONCLUSIONS MR Fingerprinting scans have potential to be a motion-robust and efficient method for nonsedated infants. LEVEL OF EVIDENCE 2 TECHNICAL EFFICACY STAGE: 1.
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Affiliation(s)
- Dan Ma
- Biomedical Engineering, Case Western Reserve University, Cleveland, OH
| | - Chaitra Badve
- Radiology, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Jessie EP Sun
- Radiology, Case Western Reserve University, Cleveland, OH
| | - Siyuan Hu
- Biomedical Engineering, Case Western Reserve University, Cleveland, OH
| | - Xiaofeng Wang
- Quantitative Health Science, Cleveland Clinic, Cleveland, OH
| | - Yong Chen
- Radiology, Case Western Reserve University, Cleveland, OH
| | - Ameya Nayate
- Radiology, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Michael Wien
- Radiology, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Douglas Martin
- Radiology, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Lynn T Singer
- Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland
| | - Jared C. Durieux
- Radiology, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Chris Flask
- Radiology, Case Western Reserve University, Cleveland, OH
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Altahawi F, Owens A, Caruso CH, Wetzel JR, Strnad GJ, Chiunda AB, Spindler KP, Subhas N. Development and Operationalization of an Automated Workflow for Correlation of Knee MRI and Arthroscopy Findings. J Am Coll Radiol 2024; 21:609-616. [PMID: 37302680 DOI: 10.1016/j.jacr.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 03/23/2023] [Accepted: 04/06/2023] [Indexed: 06/13/2023]
Abstract
OBJECTIVE In this study, we sought to establish and evaluate an automated workflow to prospectively capture and correlate knee MRI findings with surgical findings in a large medical center. METHODS This retrospective analysis included data from patients who had undergone knee MRI followed by arthroscopic knee surgery within 6 months during a 2-year period (2019-2020). Discrete data were automatically extracted from a structured knee MRI report template implementing pick lists. Operative findings were recorded discretely by surgeons using a custom-built web-based telephone application. MRI findings were classified as true-positive, true-negative, false-positive, or false-negative for medial meniscus (MM), lateral meniscus (LM), and anterior cruciate ligament (ACL) tears, with arthroscopy used as the reference standard. An automated dashboard displaying up-to-date concordance and individual and group accuracy was enabled for each radiologist. Manual correlation between MRI and operative reports was performed on a random sample of 10% of cases for comparison with automatically derived values. RESULTS Data from 3,187 patients (1,669 male; mean age, 47 years) were analyzed. Automatic correlation was available for 60% of cases, with an overall MRI diagnostic accuracy of 93% (MM, 92%; LM, 89%; ACL, 98%). In cases reviewed manually, the number of cases that could be correlated with surgery was higher (84%). Concordance between automated and manual review was 99% when both were available (MM, 98%; LM, 100%; ACL, 99%). CONCLUSION This automated system was able to accurately and continuously assess correlation between imaging and operative findings for a large number of MRI examinations.
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Affiliation(s)
| | - Amirtha Owens
- Imaging Institute, Cleveland Clinic, Cleveland, Ohio
| | | | | | - Gregory J Strnad
- Orthopaedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Allan B Chiunda
- Imaging Institute, Cleveland Clinic, Cleveland, Ohio; Director of Clinical Effectiveness and Innovations and Brentwood Foundation Chair in Research and Data Analytics
| | - Kurt P Spindler
- Director of Clinical Research and Outcomes, Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida
| | - Naveen Subhas
- Vice Chair of Clinical Effectiveness and Efficiency, Imaging Institute, Cleveland Clinic, Cleveland, Ohio
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Colucci PG, Gao MA, Schweitzer AD, Chang EW, Riyahi S, Taya M, Lu C, Ballon D, Min RJ, Prince MR. A Novel Hands-on Approach Towards Teaching Diagnostic Radiology Residents MRI Scanning and Physics. Acad Radiol 2023; 30:998-1004. [PMID: 36642587 DOI: 10.1016/j.acra.2022.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 11/25/2022] [Accepted: 12/03/2022] [Indexed: 01/15/2023]
Abstract
RATIONALE AND OBJECTIVES Traditional approaches towards teaching magnetic resonance imaging (MRI) scanning and physics have limitations that a hands-on course may help overcome. A dedicated week of MRI instruction may help improve radiology resident confidence and competence. Additional benefits may include improved physician-technologist communication and accelerated mastery of MRI safety. MATERIALS AND METHODS Surveys and tests were approved by our Program Evaluation Committee and administered at the beginning and at the end of this one-week course. The course consisted of protected reading time as well as practice scanning with a research magnet and assisting with clinical scanning under the close supervision of a licensed MRI technologist. Eighteen senior residents (nine third-year and nine fourth-year) participated in this course during its first year. RESULTS Few residents had previous experience with MRI physics, scanning, or research prior to residency. After this course, mean resident confidence increased by 0.47 points (3.33 vs 2.86; p=0.01) on a five-point Likert scale. Understanding of MRI physics, as measured by pre- and post-tests, increased by 22% (0.72 vs 0.50; p<0.01), corresponding to a large effect size of 1.29 (p<0.001). Resident feedback reported that this course was efficacious (5/5), engaging (4.9/5), and had optimal faculty oversight. The most highly rated component of the course was the opportunity to experiment with the research MR scanner (5/5). CONCLUSION A dedicated week of MRI education was highly rated by residents and associated with improvements in confidence and understanding, suggesting a positive correlation between confidence and competence. Additional metrics, such as trends in scores on the American Board of Radiology's Core Examination over the next several years, may further support the apparent benefits of this hands-on MR course.
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Affiliation(s)
| | - Madeleine A Gao
- Hospital For Special Surgery, New York, New York; SUNY Downstate Health Sciences University, Brooklyn, New York
| | | | - Eileen W Chang
- NewYork-Presbyterian Hospital / Weill Cornell Medicine, New York, New York
| | - Sadjad Riyahi
- NewYork-Presbyterian Hospital / Weill Cornell Medicine, New York, New York; SUNY Downstate Health Sciences University, Brooklyn, New York
| | - Michio Taya
- NewYork-Presbyterian Hospital / Weill Cornell Medicine, New York, New York
| | - Connie Lu
- NewYork-Presbyterian Hospital / Weill Cornell Medicine, New York, New York
| | - Doug Ballon
- Citigroup Biomedical Imaging Center / Weill Cornell Medicine, New York, New York
| | - Robert J Min
- NewYork-Presbyterian Hospital / Weill Cornell Medicine, New York, New York
| | - Martin R Prince
- NewYork-Presbyterian Hospital / Weill Cornell Medicine, New York, New York
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Thurman P, Zhuang E, Chen HH, McClain C, Sietsema M, Fernando R, McDiarmid MA, Hines SE. Characteristics Associated With Health Care Worker Knowledge and Confidence in Elastomeric Half-Mask Respirator Use. J Occup Environ Med 2022; 64:802-807. [PMID: 35704776 PMCID: PMC9426319 DOI: 10.1097/jom.0000000000002611] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study evaluated health care workers' (HCWs') knowledge and confidence in using elastomeric half-mask respirator (EHMR) attributes known to influence usage. METHODS Health care workers were surveyed regarding their EHMR donning and doffing experience. Respondents were categorized into competency categories based on their scores. Category differences were analyzed using χ 2 and multiple logistic regression. RESULTS Seventy-two percent showed high levels of EHMR donning and doffing knowledge and confidence (mastery); however, 21% had greater confidence than knowledge (misinformed). Respiratory therapists had greater odds of mastery than other HCWs ( P < 0.05), whereas those working in medical/surgical and pediatric units had greater odds of doubt than other HCWs ( P < 0.01). CONCLUSIONS Although most HCWs show high knowledge and confidence with EHMR use, strategies to confirm respirator use competency may ensure greater HCWs protection.
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Burns J, Chetlen A, Morgan DE, Catanzano TM, McLoud TC, Slanetz PJ, Jay AK. Affecting Change: Enhancing Feedback Interactions with Radiology Trainees. Acad Radiol 2022; 29 Suppl 5:S111-S117. [PMID: 34217615 DOI: 10.1016/j.acra.2021.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 05/15/2021] [Accepted: 05/17/2021] [Indexed: 11/01/2022]
Abstract
Feedback is a critical part of the learning process and is a valuable tool to empower adult learners. Modern feedback theory places the learner at the center of the feedback encounter. Individual and institutional barriers to effective giving and receiving of feedback can be overcome through education and attention to the form and content of feedback. We review the elements of effective feedback and address issues of framing, environmental, and social factors which aid in providing psychological safety and trust, as necessary elements to create a culture of feedback in radiology training programs. We provide practical strategies to empower learners with the necessary skills to solicit, receive, and reflect on feedback.
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Jaspan V, Schaye V, Parsons AS, Kudlowitz D. Lessons in clinical reasoning ‒ pitfalls, myths and pearls: a case of recurrent pancreatitis. Diagnosis (Berl) 2021; 9:288-293. [PMID: 34882358 DOI: 10.1515/dx-2021-0035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 11/17/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Cognitive biases can result in clinical reasoning failures that can lead to diagnostic errors. Autobrewery syndrome is a rare, but likely underdiagnosed, condition in which gut flora ferment glucose, producing ethanol. It most frequently presents with unexplained episodes of inebriation, though more case studies are necessary to better characterize the syndrome. CASE PRESENTATION This is a case of a 41-year old male with a past medical history notable only for frequent sinus infections, who presented with recurrent episodes of acute pancreatitis. In the week prior to his first episode of pancreatitis, he consumed four beers, an increase from his baseline of 1-2 drinks per month. At home, he had several episodes of confusion, which he attributed to fatigue. He underwent laparoscopic cholecystectomy and testing for genetic and autoimmune causes of pancreatitis, which were non-revealing. He was hospitalized 10 more times during that 9-month period for acute pancreatitis with elevated transaminases. During these admissions, he had elevated triglycerides requiring an insulin drip and elevated alcohol level despite abstaining from alcohol for the prior eight months. His alcohol level increased after consumption of complex carbohydrates, confirming the diagnosis of autobrewery syndrome. CONCLUSIONS Through integrated commentary on the diagnostic reasoning process, this case underscores how overconfidence can lead to premature closure and anchoring resulting in diagnostic error. Using a metacognitive overview, case discussants describe the importance of structured reflection and a standardized approach to early hypothesis generation to navigate these cognitive biases.
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Affiliation(s)
- Vita Jaspan
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Verity Schaye
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Andrew S Parsons
- Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - David Kudlowitz
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
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