Do you keep track of missed findings?

[Neuronix]

As a radiation oncologist, I review most of my patient's MRIs. I also follow the patients longitudinally.

I do find things that are missed. Also, sometimes we encounter something later when they are larger but were tiny and only seen in retrospect on the prior scan.

Nobody is perfect. Do you want to know about these misses? I usually don't say anything because I think it's pretty awkward. So I'm just curious what you all think about this.

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[clutch21]

Yes. Misses suck, but they happen, and are important for the radiologist to know about. Knowing about them is crucial for growth, and can alter search patterns moving forward.

As a minimalist in my reporting style, I’ll add that sometimes ordering providers confuse misses for purposely ignored findings that aren’t clinically important and lead to unnecessary work up (e.g. thyroid nodules and small pancreatic cysts in the senescent population).

 

[maxxor]

Also, sometimes we encounter something later when they are larger but were tiny and only seen in retrospect on the prior scan.

There’s “true misses”, indeterminate things that could have turned into something, and omitted incidentals. Which are we talking about here?

I think it’s helpful to discuss these, verbally, with a rad. Maybe phrase it as a “could you take a look at xx patient” and point out what you are curious about.

Those tiny things could also have never changed. When things are early, it is difficult to prospectively call post tx change or recurrence or new disease.

There is just as much of a likelihood that something never changes but you are only seeing the ones that grow with the tremendous diagnostic augmentation of time.

 

[Neuronix]

Today's example was a punctate parenchymal brainstem T1 post-contrast enhancement 4 months ago that wasn't in the report at all and clearly visible in retrospect that blossomed into a 1.1 cm midbrain metastasis.

I call that an "indeterminate thing that could have turned into something". I do see some true misses as well. I'm not blaming anyone. I miss things too. Nobody is perfect. Just a question of whether radiologists want to be notified about these things. I like to be notified anytime I could make things better, but I know that some people get insecure or defensive.

Omitted incidentals is another topic. What's significant enough to put in a report is at the discretion of the radiologist in my opinion. The ones that are too detailed can be confusing and I'm often left explaining complicated reports to patients who read their reports but don't understand them.

 

[Radology]

Unless you would have acted on a 4 mm ditzel 4 months ago, I would consider that example a clinically insignificant miss and not worth telling the radiologist, IMO.

It’s only a miss in retrospect because it ended up being a met, but you got the appropriate short interval follow up anyways which is all that would have been recommended best case

I like to be notified of misses, but not gray area ones that are only misses in retrospect. if a thoracic surgeon told me that I missed a 3 mm lung nodule that turned into cancer years later I would not consider that valuable feedback..

 

[Neuronix]

Unless you would have acted on a 4 mm ditzel 4 months ago, I would consider that example a clinically insignificant miss and not worth telling the radiologist, IMO.

I would have gotten a shorter term follow-up (2 months instead of 4) for this particular clinical scenario with indeterminate punctate brain lesion and patient would have been treated sooner.

 

[Radology]

I would have gotten a shorter term follow-up (2 months instead of 4) for this particular clinical scenario with indeterminate punctate brain lesion and patient would have been treated sooner.

In your experience, would treating a patient with a hypothetical 7 mm brain stem metastasis result in a significantly improved outcome compared to treating a patient with an 11 mm brain stem metastasis 2 months later?

I’m not a rad onc, but If the answer is “probably not”, then it’s not worth the feedback in my opinion

 

[Neuronix]

In your experience, would treating a patient with a hypothetical 7 mm brain stem metastasis result in a significantly improved outcome compared to treating a patient with an 11 mm brain stem metastasis 2 months later?

I’m not a rad onc, but If the answer is “probably not”, then it’s not worth the feedback in my opinion

The smaller the better. This patient was lucky she didn't develop symptoms.

Normally even punctate brain lesions are noted in our neuroimaging exams because we are a high volume brain malignancy center.

In retrospect really should have been like a 1 month to 6 weeks follow up on brainstem lesions. You don't sleep on those mets.

 

[Radology]

if you think it will make them a better radiologist, especially if it’s a new name on the report you are not used to seeing, feel free to let them know

95% of us will appreciate the feedback

 

[GadRads]

I like seeing my misses, and they have altered my search pattern. The average radiologist in my shop reads 20000 to 30000 studies per year. Impossible to be perfect.

 

[Cognovi]

Let them know in a discreet way if possible (eg, an exploding Epic message). As you said, it's awkward, mostly because we don't want a paper trail that's discoverable for our misses (anything outside of our usual QA process), but we also definitely want to know.

Punctate brain mets are certainly a common miss I come across and many of us would do well to augment our search patterns with some of the less commonly affected areas (eg, brainstem).

While I have a rad onc's attention... do you like it when we enumerate each metastasis with an image number? I see some rads just say, multiple mets, largest X in this lobe, and move on but that seems to me to be entirely unhelpful for the rad onc planning SRS. Or maybe they are expecting you to search all the images yourself. What's the max we should enumerate before a reasonable rad onc gives up and just does WBRT?

 

[Neuronix]

While I have a rad onc's attention... do you like it when we enumerate each metastasis with an image number? I see some rads just say, multiple mets, largest X in this lobe, and move on but that seems to me to be entirely unhelpful for the rad onc planning SRS. Or maybe they are expecting you to search all the images yourself. What's the max we should enumerate before a reasonable rad onc gives up and just does WBRT?

For the first report type, it does put all the responsibility on me to find the mets. It's my job to do that, and I'm happy to do it. I do like having radiology as a backup though. Sometimes I find little things the radiologist doesn't report, and sometimes they report little things I don't find. The reality is that little brain mets can be easily missed, so having an extra pair of eyes can help.

Where I rely on the report more than anything is two things. First, if there's any sort of differential diagnosis, I am lost quickly. It's just not part of a rad onc's wheelhouse. We know about cancer imaging to some degree and that's about it. Second, I'm doing a targeted review. That case I posted about had a meningioma in the past, so I was paying attention to that stable area not expecting a tiny brain met that was obvious in retrospect.

As for detail of enumeration, image number can be helpful. If you mention something that I can't find, I will call you. I make sure my treatment plan includes everything you reported unless I have a good reason not to.

How many is the maximum? It depends on the case and the rad onc or center. One review says up to 10 if you want a firm number.

https://www.practicalradonc.org/article/S1879-8500(22)00054-6/fulltext

The reality is that it's usually the size of the brain mets that drives prognosis, not number. Also, tech is making it easier to treat larger numbers of brain mets. As such, there will never be a firm answer to that question. I think 10 is also reasonable because any reasonable rad onc is not expecting you to enumerate huge numbers of individual mets.

 

[evilbooyaa]

Stumbled upon this thread bored today (also a Rad Onc)

Thanks for all your feedback. Can definitely echo similar feelings, at times dependent on the reading Radiologist at my center... Hindsight 20/20 is one thing, clear misses I usually will message/e-mail asking them to take a look and let me know what they think of x/y/z. At times I've felt something is mets that they feel is more likely to be a stroke or something non-oncologic. Rads and I both seem to ber ight in those discordant cases about 50% of the time.

@Neuronix - a pt with a meningioma developed a brain stem met?

Agree with everything Neuronix has said - giving slice numbers or pointing out with a flag to small/punctate things is always a nice bonus - not necessary but beneficial. I would say counting anything 10 or less would be fine - more than that I would say most (not all) are recommending some form of whole brain anyways. Anyone SRSing more than 10 brain mets is capable of finding the lesions on their own.

How do you DR guys/gals reconcile reports where report from X date states 'stable 7mm lung lesion' when the report from X-3 months states 'no visible lung lesions', of course read by 2 different radiologists?

 

[Radology]

Stumbled upon this thread bored today (also a Rad Onc)

Thanks for all your feedback. Can definitely echo similar feelings, at times dependent on the reading Radiologist at my center... Hindsight 20/20 is one thing, clear misses I usually will message/e-mail asking them to take a look and let me know what they think of x/y/z. At times I've felt something is mets that they feel is more likely to be a stroke or something non-oncologic. Rads and I both seem to ber ight in those discordant cases about 50% of the time.

@Neuronix - a pt with a meningioma developed a brain stem met?

Agree with everything Neuronix has said - giving slice numbers or pointing out with a flag to small/punctate things is always a nice bonus - not necessary but beneficial. I would say counting anything 10 or less would be fine - more than that I would say most (not all) are recommending some form of whole brain anyways. Anyone SRSing more than 10 brain mets is capable of finding the lesions on their own.

How do you DR guys/gals reconcile reports where report from X date states 'stable 7mm lung lesion' when the report from X-3 months states 'no visible lung lesions', of course read by 2 different radiologists?

If the stability means it’s benign, I will say it was present on retrospect. No harm done

If it’s stable but still indeterminate, I will recommend a follow up. No harm done.

If it’s growing and was missed…then I’m very careful about my wording so as to not throw the prior rad under the bus

 

[Neuronix]

@Neuronix - a pt with a meningioma developed a brain stem met?

Past history of locally advanced NSCLC, no prior brain mets. First sign of metastasis.

 

[Cognovi]

If the stability means it’s benign, I will say it was present on retrospect. No harm done

If it’s stable but still indeterminate, I will recommend a follow up. No harm done.

If it’s growing and was missed…then I’m very careful about my wording so as to not throw the prior rad under the bus

I do the same.

For the third scenario - Sometimes I don't describe that it is enlarged, but clearly conclude that it's a neoplasm/malignancy/etc. But then I'll get an email/message from the referrer/ED/NP/etc asking me to addend it to say if it was there before and grown. To which I sometimes acquiesce but I don't really see how that serves the patient any better. I already concluded that it's a bad actor, do I really need to document that it has grown?

 

[Radology]

I do the same.

For the third scenario - Sometimes I don't describe that it is enlarged, but clearly conclude that it's a neoplasm/malignancy/etc. But then I'll get an email/message from the referrer/ED/NP/etc asking me to addend it to say if it was there before and grown. To which I sometimes acquiesce but I don't really see how that serves the patient any better. I already concluded that it's a bad actor, do I really need to document that it has grown?

I say “Newly visible” or “not well seen on prior study” or if it was really obvious then “Seen to a better extent than on the prior study”

It’s your report, not theirs. Like you said, there is nothing you are adding to the patients care by saying it was missed. The terminology above is vague enough that you’re not putting a target on your colleagues back while still saying it’s a change

 

[GadRads]

I say “Newly visible” or “not well seen on prior study” or if it was really obvious then “Seen to a better extent than on the prior study”

It’s your report, not theirs. Like you said, there is nothing you are adding to the patients care by saying it was missed. The terminology above is vague enough that you’re not putting a target on your colleagues back while still saying it’s a change

Agree. I never imply that something was missed. Every one misses, some more than others, but we all do. If you are 99.9% accurate (which is very very hard to do, if not impossible), it means you will have one bad miss in 1000 cases. If you read 20,000 cases per year, then that is 20 cases that could get you in trouble per year. In a 5 year career, that is 100 misses.

I hardly ever addend my report to imply something was missed. I get annoyed when referrers think they can do a better job than us. They cannot and it is not even close taking into consideration how much volume and how fast we read, usually with limited/zero history, and (not uncommonly) very misleading history/indication.

I have seen plenty obvious misses on radiation pretreatment CTs that were not reviewed by a radiologist. I just read the study in front of me as if it is a new finding. Rarely, the rad onc docs will reach out to compare with the radiation planning CT.

 

[Ho0v-man]

Last week I called the left renal cyst but I foolishly “missed” the “right lower pole sub centimeter renal hypodensity too small to characterize but is statistically most likely to represent a simple cyst” because I was trying to catch up an endless list of strokes and trauma.

I will carry this shame to my grave…

 

[colbgw02]

I've been doing this for awhile, and I'm still surprised at how little non-radiologist physicians understand about what we do. I mean, I don't know anything about being a urologist, but I also don't get all uppity when I see a uroma status post ureteral stent placement because I think I could have done a better job.

More specifically, I don't think people really get on a basal level why we call it an interpretation. Data vs. information. That is, I didn't "miss" the tiny fat-containing umbilical hernia. I chose not to mention it because 1) they're extraordinarily common, 2) they're rarely of clinical significance, 3) extraneous information lowers the SNR of my report and distracts from what I really want to convey, and--most importantly--4) I'm a physician with (chances are) just as much education and training as you, who is capable of deciding what is important.

I get that it's less than ideal that your patient's tiny fat-containing umbilical hernia just happens to be symptomatic and that you ordered the CT specifically for that reason, but the history that I got was "abdominal pain, unspecified". So no, I didn't miss the hernia. I made a calculated decision about what was best for the patient, the ordering provider, and the other patients whose exams need to be read in a timely manner based on the best information available.

 

[GadRads]

I've been doing this for awhile, and I'm still surprised at how little non-radiologist physicians understand about what we do. I mean, I don't know anything about being a urologist, but I also don't get all uppity when I see a uroma status post ureteral stent placement because I think I could have done a better job.

More specifically, I don't think people really get on a basal level why we call it an interpretation. Data vs. information. That is, I didn't "miss" the tiny fat-containing umbilical hernia. I chose not to mention it because 1) they're extraordinarily common, 2) they're rarely of clinical significance, 3) extraneous information lowers the SNR of my report and distracts from what I really want to convey, and--most importantly--4) I'm a physician with (chances are) just as much education and training as you, who is capable of deciding what is important.

I get that it's less than ideal that your patient's tiny fat-containing umbilical hernia just happens to be symptomatic and that you ordered the CT specifically for that reason, but the history that I got was "abdominal pain, unspecified". So no, I didn't miss the hernia. I made a calculated decision about what was best for the patient, the ordering provider, and the other patients whose exams need to be read in a timely manner based on the best information available.

This happened to me a few months ago. Very small fat containing umbilical hernia with zero inflammatory change. I did not mention it because they are soooo common and 99.99% of the time are insignificant. The history I got for the CT was "pain".

The surgeon ended up telling the patient I missed his hernia. The patient then filed a complaint with patient relations and safety.

Utterly ridiculous.

 

[maxxor]

This happened to me a few months ago. Very small fat containing umbilical hernia with zero inflammatory change. I did not mention it because they are soooo common and 99.99% of the time are insignificant. The history I got for the CT was "pain".

The surgeon ended up telling the patient I missed his hernia. The patient then filed a complaint with patient relations and safety.

Utterly ridiculous.

Yes. This is why I now err on the side of more incidentals unfortunately. Also these “tiny umbilical hernias” that the surgeons love to point out are just as likely to just be an “outie”…

There is nothing more burnout rage inducing than some drive by report assassination which pisses the patient off about something that’s clinically trivial which then leads to a complaint or some other waste of time. All so some referring can flex that they “know how to read imaging better than the radiologist”.

 

[Radology]

I got a call from an angry doctor for not comparing the size of a simple renal cyst on ultrasound to the size on a prior contrast enhanced MRI

Not an anxious patient—a doctor. Who went to medical school and training and all

 

[maxxor]

I got a call from an angry doctor for not comparing the size of a simple renal cyst on ultrasound to the size on a prior contrast enhanced MRI

Not an anxious patient—a doctor. Who went to medical school and training and all

My favorite is when they ask me to compare the size and the measurements are in the report...

 

[callmeanesthesia]

Pain doc here. Came looking for a thread like this to get your advice. What (if anything) do you do about a truly egregious miss, aside from letting the reading radiologist know? I’ve seen 2 in the past 5 years so I know you must see them frequently. I’m talking a huge mass that a first year med student wouldn’t have missed. Both, unfortunately, had these images done several months before they made their way to me.

The first one had some extenuating technical circumstances (MRI was c-spine, tech must have seen this on the scout and got a sagittal brain image, but the radiologist only read the c spine even though the brain image was included in the scan. Still missed the brainstem herniation though).

The second one is the c spine at about C6-7. That thing was visible for the whole lower third of the axials.

 

[Radology]

If the rad is a jerk and blows you off then I would consider going to the section chief or even department chair with the feedback.

If he admits he just flat out messed up, what else is there to do?

Not trying to forgive this, but I still remember a case when I was a first year attending when I was interrupted 90% of the way through a study to do a fluoro case. Came back to my station and on quick review i thought the study was done. Hit sign, got a call 30 mins later questioning why I didn’t mention the obviously fractured hip I diagnosed on x ray hours earlier. I was embarrassed as all hell, and changed my templates to never allow the mistake to happen again.

We are human, and sometimes we make really dumb mistakes, even really bad ones like this. Finding an isolated one in the wild doesn’t mean you’re dealing with a reckless buffoon, or an incompetent radiologist who needs disciplinary action above simple feedback.

 

[colbgw02]

Pain doc here. Came looking for a thread like this to get your advice. What (if anything) do you do about a truly egregious miss, aside from letting the reading radiologist know? I’ve seen 2 in the past 5 years so I know you must see them frequently. I’m talking a huge mass that a first year med student wouldn’t have missed. Both, unfortunately, had these images done several months before they made their way to me.

The first one had some extenuating technical circumstances (MRI was c-spine, tech must have seen this on the scout and got a sagittal brain image, but the radiologist only read the c spine even though the brain image was included in the scan. Still missed the brainstem herniation though).

The second one is the c spine at about C6-7. That thing was visible for the whole lower third of the axials.


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I'm not trying to give you a hard time. I think you asked an honest, legitimate question borne of good faith. It's also clear, based on the images you posted, that these abnormalities are clear and obvious. But let's unpack the numbers a little.

Let's assume for a moment that this hypothetical radiologist read 100 cases per day (ha!), every day, every year, for the 5 years in question. Let's further assume that this radiologist works about 210 shifts per year. Just trying to keep the numbers realistic but also simple.

That means that a single radiologist working at that rate will read about 105,000 in a five-year period. What is considered an acceptable miss rate with those numbers? Because those two studies alone represent a 0.0019% of the total studies interpreted.

Clearly, this is not a comprehensive look at this one (hypothetical) radiologist's work, but let me ask a question. If you routinely referred your patients to a single surgeon for appendectomies, how many post-op abscesses would give you pause before referring to a different surgeon? Because at this complication rate, from your perspective, the surgeon is only getting 1 post-op abscess out of every 52,000 appendectomies.

So why do we treat radiology misses any different than any other medical complication?

I don't know the answer, but I do know that human beings--all humans--will reliably neglect to notice a retrospectively obvious abnormality a certain percentage of the time irrespective of other circumstances. I believe that conclusion comes from studying airplane spy photographs from WW2, but I admit that I have had a hard time confirming that.

My point? Start thinking about radiology misses in the same way that we think about all other medical errors. All of a sudden, we don't look so bad.

 

[callmeanesthesia]

I'm not trying to give you a hard time. I think you asked an honest, legitimate question borne of good faith. It's also clear, based on the images you posted, that these abnormalities are clear and obvious. But let's unpack the numbers a little.

Let's assume for a moment that this hypothetical radiologist read 100 cases per day (ha!), every day, every year, for the 5 years in question. Let's further assume that this radiologist works about 210 shifts per year. Just trying to keep the numbers realistic but also simple.

That means that a single radiologist working at that rate will read about 105,000 in a five-year period. What is considered an acceptable miss rate with those numbers? Because those two studies alone represent a 0.0019% of the total studies interpreted.

Clearly, this is not a comprehensive look at this one (hypothetical) radiologist's work, but let me ask a question. If you routinely referred your patients to a single surgeon for appendectomies, how many post-op abscesses would give you pause before referring to a different surgeon? Because at this complication rate, from your perspective, the surgeon is only getting 1 post-op abscess out of every 52,000 appendectomies.

So why do we treat radiology misses any different than any other medical complication?

I don't know the answer, but I do know that human beings--all humans--will reliably neglect to notice a retrospectively obvious abnormality a certain percentage of the time irrespective of other circumstances. I believe that conclusion comes from studying airplane spy photographs from WW2, but I admit that I have had a hard time confirming that.

My point? Start thinking about radiology misses in the same way that we think about all other medical errors. All of a sudden, we don't look so bad.

I get where you’re coming from, but I don’t think a surgical aite infection is an apt comparison for a miss this egregious. Lots of outside factors like patient hygiene, smoking status, hospital cleanliness go into that. Maybe a wrong side joint replacement or amputation. And to me that raises serious questions about the competence of the surgeon or at best implies that they are severely compromising care for the sake of speed.

 

[Radology]

Would an accidental bowel perforation during ventral hernia repair be a better example?

Or a pharyngeal rupture and subsequent mediastinitis during a routine acdf?

Maybe a dislodged tooth during intubation that was aspirated, leading to a severe pneumonia?

Massive hemoperotineum hours after a surgery where the op note says “estimated blood loss: <5ml” 🤨

I’ve seen all of these this month alone. It’s easy for me to point at these mistakes and call them all sloppy doctors. But more likely they are human beings working in a field where errors occur

Hate to break it to you, but if you had 10 subspecialists looking over your shoulder at every moment of care for every patient, you’d probably be caught making a few catastrophic errors that you dont even realize you are making