iRADiX

The Technical Review Meeting is a very useful part of any department.

The Technical Review Meeting (TRM)

Is setting up a Radiology department similar to an adventure? Things can be pretty challenging at times. In previous Blog http://www.iradix.in/488-Please-repeat.html we had touched upon this topic giving the example of plain radiographs. We can now examine how such situations may play out in other imaging modalities.

The adventurer, mountaineer and author Chris Bonnington tells of his ground rules of adventure as a journey, or a sustained endeavor, in which there are the elements of risk and of the unknown, which have to be overcome by the physical skills of the individual. Radiologists starting a new Imaging centre from scratch may have to use a lot of intellectual energy and skills and face up to many unknowns.

Working in an already running place is very different from starting a centre from naught, establishing the protocols and reputation of images and reporting and also facing up to clinicians of different training and temperament. The nuances in foreign settings add further flavor to experience (See blogs: http://www.iradix.in/413-Violence-Management-Strategies-Categories-and-Specifics.html) and http://www.iradix.in/302-Dignified-solutions-302.html

for further detailed narrations)

GET ME A HIGH RESOLUTION IMAGE

Ask any radiologist or technologist working in a modern imaging centre and he will tell that the words “High Resolution” have a definite meaning when applied to CT chest. However, clinicians may just write “Do High Resolution CT” without realizing what that means, leading to confusion in the minds of the technicians.

(See blog: http://www.iradix.in/415-Dealing-with-The-Internet-Armed.html for a more complete account of the airs of “The Chest Expert Couple”...fresh from DNB and declarative rather than discussing…You do not know anything...)

Computed tomography (CT) and High Resolution CT (HRCT) play a central and important role in evaluation of focal and diffuse lung disease. Patients with focal lung disease are best evaluated with CT (7-10 mm collimation) of the entire thorax to exclude additional focal lung disease. Because contiguous sections are usually obtained with CT, small mediastinal and lung structures are less likely to be overlooked than with usual HRCT of the thorax (1.0-1.5 mm sections at 7 mm interval), which does not image 85-90% of the tissue because of thin collimation. After console review of the CT examination and when CT findings are insufficient for a diagnosis, the HRCT technique may be used to further delineate focal disease (1)

This reminded me of an old debate in Education.

FOUNTAINS OF EXPERIENCE: SENSATION VERSUS REFLECTION

In An Essay Concerning Human Understanding, Locke argued that ideas come from two “fountains” of experience: Sensation, through which perceptions are conveyed into the mind, and reflection, whereby the mind works with perceptions forming ideas. The Italian philosopher Giambattista Vico argued about the need of a kind of reasoning common sense provides. Common sense, acquired through the experience of poets, orators and people of prudence, teaches the young the importance of working with probabilities prior to education in logic. To train the youth first in logic in the absence of common sense is to teach them to make judgments before they have the knowledge necessary to do so. Vico’s aim was to emphasize the importance of practical judgment in education, an echo of the ideals of Locke and a prefiguring of Rousseau (we will examine this concept further in coming articles as there are many self-styled experts who do not require a trained radiologist’s opinion).

In Radiology, errors in interpretation can generally be categorized as either perceptual or cognitive in nature. (2)

Perceptual errors are those in which the radiologist does not see the abnormality, resulting in a false-negative interpretation. Cognitive errors, on the other hand are those in which the abnormality is identified but the meaning or significance of the abnormality is not recognized.

Cognitive errors can result in false-positive interpretation if, for example, a normal variant is mistaken for a pathologic condition. Conversely, they can result in true-positive interpretation but mis-classification if the radiologist arrives at the wrong conclusion or diagnosis due to misleading information, a lack of knowledge, or a limited differential diagnosis.

SOME EXPERIENCES AND POTENTIAL PITFALLS OF TRM

A technical review meeting with the technical staff, fellow radiologists, and clinical colleagues helps to establish common understanding of protocols and terminology. How frequently should such a meeting be held? What will be the chorum of a TRM? These will vary from institution to institution and different practice settings. In some places where I have worked, the technicians were very dominant and in touch with low-middle level management who served as informers to higher management. They may not like such a review meeting and one has to then tailor down one’s approach according to the circumstances.

Notes:

1. Swensen SJ: Focal Lung disease: CT and High Resolution CT Applications

Radiographics: 1994; 14:169-181

2. Bahrami S, Yim CM: Quality Inititiatives: Blind spots at Brain Imaging

Radiographics: 2009; 29:1877-1896