getting the call wrong

Tuesday, September 27, 2016

One wonders why anybody would aspire to be a referee. It is a thankless job that somebody has to do, especially in the amateur ranks. There is some glamour in being on the field, ice or court as the best players in the world perform, and in that regard professional referees and umpires are also the best at what they do. Less glamourous are the little league umpires or soccer referees who suffer just as much scorn ads the pros. But it’s the beginning of the week and fans, especially those of the losing team, are vocal in blaming officiating as the cause of their favorite team’s demise.

There are very few sports that have black and white results. Racing against the clock provides an arbitrary score but most team sports are at the mercy of the officials. The same is true in medicine. One would think that doctors could agree on the results of an X-ray, blood test or EKG, but one might be wrong. Black and white don’t often exist in medicine and even grey is often in dispute. Not that one shouldn’t trust test results, but they are just one part of a patient’s evaluation and need to be taken into context.



Let’s consider the basic X-ray. The radiologist can take as long as needed to interpret the images, but the in box is always being filled with new cases to read and there is a time crunch. It’s no different than instant replay; the referees could take forever to review play to the detriment of the game and the enjoyment of the fan. Many studies have looked at the radiology miss rate and it tends to be about 3-5%. Interestingly, that percent stays about the same whether the radiologist quickly looks at the film or whether inordinate amount of time is spent reviewing the images. One study reviewed chest X-rays and defined visual dwell as spending too much time on one specific part of the film. Those who spent too much time had the same error rate as the radiologist who spent less than 4 seconds reading an X-ray. The researchers’ conclusion: “Common experience in radiology suggests that many errors are of little or no significance to the patient, and some significant errors remain undiscovered.”




Like radiologists, cardiologists (heart specialists) often interpret tests without physically seeing and touching the patient. Presumably, a test result is a test result, but just like fans from opposing teams who can’t agree on what constitutes a catch in the NFL, cardiologists reading the same test may come to different conclusions. Echocardiograms are ultrasounds of the heart that help diagnose structural abnormalities. Add exercise (or inject a chemical to get the heart to do more work and the echo can help diagnose narrowing of the coronary arteries. Researchers had two or more cardiologists review echocardiograms and compared their interpretations. In patients with normal hearts and those with bad heart disease, the docs agreed. But is patients with intermediate disease, cardiologists could only agree 75% of the time.

For most patients, diagnosis and treatment involves being touched by a health care provider and test results are put in perspective. Clinical situation and tests have to make sense together and the art of medicine involves interpreting the situation. There may not be a wrong, just a gray shade of not right. This perhaps does not satisfy the Monday morning quarterback since everybody, including medical people strive for perfect. But in the imprecise world that is medicine, black and white don’t routinely exist.

Radiology Quality Institute. White Paper: Diagnostic Accuracy in Radiology 2012

Brady A, etal. Discrepancy and Error in Radiology. Ulster Med J. 2012 81(1).

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