How Rad is this? Academic Radiology dedicated "Overdiagnosis Issue" Aug 2015

The Preventing Overdiagnosis conference in Bethesda, MD this year was amazing for many reasons.

One of my favourite parts? Meeting all the people who are doing excellent work in the area of preventing harm to patients from unnecessary tests and treatments! I've been lucky to "know" quite a few motivated people on Twitter, but putting faces to names to twitter handles was really something.

Imaging my delight to meet @RogueRad, aka Dr Saurabh Jha, the developer of Value of Imaging and Assistant Professor of Radiology at the Hospital of the University of Pennsylvania, with a background (and Master's) in Health Policy Research. He is really interested in uncertainty as a driver of diagnostic imaging utilization and how we decide which tests have value.

It should not be surprising then that he handed me a copy of Academic Radiology; why? The August journal, with Jha's editorial hand, was dedicated entirely to Overdiagnosis! 

You can view the contents here. It is an impressive edition, with a Guest Editorial from H. Gilbert Welch and articles ranging from breast cancer screening to PET scanning in dementia to the role of Precision Medicine in confronting overdiagnosis. While I'm less optimistic about that last point, the August edition of Academic Radiology on the whole strikes a nice combination of hope and caution, balancing under- and over- diagnosis, even explicitly in the case of and article about this in the context of Mild Traumatic Brain Injury (MTBI).

Hopefully in the coming year we'll see more medical journals dedicating themselves to this issue with the help of keen leadership like that of Dr Jha.


Incidentalomas: What they are and why we should be concerned | Jill Wruble | TEDxPenn - YouTube

At the Preventing Overdiagnosis conference, I met a wide variety of people all dedicated to the same cause: the pursuit of better care for patients by way of helping them to avoid unnecessary and harmful tests and treatments.

By chance I met Dr Jill Wruble, a radiologist at Veterans Medical Center in West Haven, Connecticut and Clinical Assistant Professor with Yale and the University of Connecticut.

We talked about incidentalomas and what could be done to help improve our handling of them. When Jill told me about her TedX talk, I knew it would be worth checking out. She models appropriate care in her practice, teaches colleagues and residents, and has been making efforts to inspire others to make sure they are using diagnostic imaging meaningfully and judiciously. And she's a pretty amazing woman - did you see that bio!?


Not sure what an incidentaloma is? Or what to do if you find one (or are told you have one)? See her 15 minute talk on the subject:



Specificity Vs Sensitivity: Who is the better radiologist?

A radiologist friend posted this illuminating article, Who is the Better Radiologist. It considers the challenges of selecting for quality, given the reality of trade-offs between sensitivity and specificity.

The article compares two fictional radiologists, one who is very detailed, never misses a thing, asks for lots of follow up testing, and is likely to over-diagnose. The other is faster, more direct, but may miss some subtle things.


If you were a patient who would you prefer read your scan, the under calling, decisive Dr. Singh or the over calling, painfully cautious Dr. Jha?

If you were a referring physician which report would you value more, the brief report with decisive language and a paucity of differential diagnoses or the lengthy verbose report with long lists on the differential?


Which would you rather have reading your images? We'd rather the careful one if the subtle thing they see is going to be a problem for us. We'd rather the more efficient one if the subtle thing they'll miss would not cause us harm.

But we can't actually choose. And the author of the article understands that.

Trade-off is a fact of life. Yes, I know it’s very un-American to acknowledge trade-offs. And I respect the sentiment. The country did, after all, send many men to the moon.

Nevertheless, whether we like it or not trade-offs exist. And no more so than in the components that make up the amorphous terms “quality” and “value.”



This is a very common problem in medicine! Balancing risk and uncertainty against avoidance of harm and cost is not something we can solve overnight, but even being aware of the struggle makes discussions with patients better-informed; that is a step forward to providing the right care.