Sie sind auf Seite 1von 9

Behavioral Ultrasound- child dental x ray

child dental x ray On or around April 1, 1980, someone decided the objective of
an ultrasound exam was a set of images. It seems plausible on the surface. It fits
the job description of ultrasound technologists, and it mirrors the role of
manufacturers. From the standpoint of medical diagnosis, though, that notion
departs from medical teachings going back to Hippocrates, probably even earlier
to the Ebers Papyrus. I am sure the originator could not have been a radiology. I
hope that behavioral psychology might provide us with an insight.

In the Beginning

The early B-Mode ultrasound settlement included physicians with a wide array of
specialty backgrounds. After some initial, and very significant, technical advances,
a lot of the daily clinical work across the country was handled by radiologists.
Along the way, cardiologists moved up to high-speed imaging from TM tracings
and obstetricians began to offer ultrasound to their own patients. Now, we have
separate ultrasonic fiefdoms in multiple areas the ER, the ICU, MSK, family,
medicine, and, at the recent AIUM, there were multiple presentations and
courses on dermatologic applications.

The early days were a simple time. There wasnt much known, you didnt have to
know much, and clinical expectations were low. Acquiring satisfactory images
took a long time, and they had a low yield of actionable information. The only
impetus for clinical usage seemed to be avoiding ionizing radiation exposure.
Most of the uses revolved around distinguishing cysts from solids for finding
fluid collections of one type or another, or for looking at movements of structures
in a fluid field.

I think of the decade from 1975 as the golden (and radiologic) Age of Ultrasound.
There was a vast amount of academic research of imaging fundamentals leading
to some major improvements in instrumentation, and there was a gigantic
deepening of clinical sophistication with a rich peer-reviewed literature. There
were some massive technical downsides. Image noise content was so high and
data acquisition so varied from place-to-place, from operator-to-operator, and
between multiple types of instruments that there was never any effective way to
establish practice standards, make education uniform, or extract quantitative
descriptors of tissue properties.

Nevertheless, the clinical results of the early experience with mechanical and
electronic scanners were very good, and the field flourished over a wide span of
diagnostic applications. An essential factor may have been due to the way
radiologists handle visual data. The starting points for all imaging modalities are
knowing where to look and how to look. The real work is in fitting information
from images with everything you know clinically about the patient and everything
you should know about what can go wrong with that patients population cohort.
The list of possibilities is prioritized by the potential lethality or severity of
probable conditions. The radiologist has to have an understanding of the utility of
every other diagnostic procedure in his or her own facility in order to select the
safest and most informative way of resolving a clinical question as a procedural
sequence.

Another covert facet of image interpretation is the ability to extrapolate the


consequences of a diagnosis. This might seem obvious in a fetal or pediatric
ultrasound study, but it is always a factor. Perhaps this is why radiologists have
been so obsessed with the pick-up rates, the sensitivity, and the specificity of
screening exams ever since the days of mobile vans for tuberculosis detection. If
you miss a tiny, eminently miss-able, lesion, the patient might lose years of life.
Over-diagnosis has its own set of painful and costly detriments.

Fast and/or Slow


My limited exposure to dual process theory is from Thinking, Fast and Slow by
Daniel Kahneman (Farrar, Strauss, Giroux, 2011 ISBN: 978-0374275631). This book
has been referred to as a masterpiece. It has won every possible award. It
explored the life work of the author and his late collaborator Amos Tversky, and it
centers on prospect theory the basis for Professor Kahnemans Nobel Prize in
Economics. The subject is treated scientifically. It describes many ingenious
experiments, which established there are two main ways people respond to
situations, referred to as fast and slow. The works of other researchers is
detailed selflessly, and there are no wild speculations. Since this work concerns
basic human behavior, it would seem logical that it applies to ultrasound, too.

Fast and slow are metaphors. The fast system is instant, automatic, unconscious,
capricious, effortless, and always on. It is triggered by unconscious perceptions
and works by ingrained associations and patterns that are very hard to change. It
is incapable of calculation. It is not influenced by statistics or objective reality. It is
gullible and can be misled. Effective ads appeal to the fast system.

Slow is rational, conscious, suspicious, and very effortful, because it involves a lot
of energy expenditure. Fast can be brilliant, but prone to systemic errors; slow
can be thorough and plodding, but it is not perfect either. Slow is mostly off,
and it can be derailed by emotionally-tainted fast perceptions, as well as a limited
knowledge base.

Ive always believed in love at first sight. That is an ultimate fast system response.
Fast is very efficient, and it works by a system of heuristics. Heuristics is a
relatively new word, coined from a Greek root related to discovery, so its
definition remains somewhat pliable. I encountered the term in college (its
probably common in grade schools now) in issues related to computer searching,
pattern recognition, and artificial intelligence. An heuristic is a fast, efficient,
down-and-dirty shortcut for getting a workable and/or reasonable, approximate
solution to a complex, sometimes analytically insoluble, problem. In Thinking,
Professor Kahneman identifies several classes of heuristic that the fast system
relies upon. One is the halo effect in which your impression becomes
generalized over the object, i.e. love at first sight = everything about the object of
your affections is lovable and perfect. Heuristics are mental habits. It is also via
heuristics that biases emerge as influencers.
A Detour to Psychiatry and Genetics

Fast has been proposed as the evolutionary default state. Each of us has a balance
point between fast and slow in our lives and work that I want to explore a little
more. People who are locked into either of these operational states exclusively
have well defined forms of psychopathology. People with very different balances
between fast and slow cannot communicate very well. People who are mainly fast
double down on their opinions, even when they have no factual substance or
foundation, and mainly slow people cannot understand the emotional fervor of
preferential fasts. All of my patients are referred, and to tell you the truth, I have
always found a lot of remote referral patterns to be somewhere between rigid
and irrational. I would guess these referrals are fast responses by practitioners
who dont know a lot about ultrasound, dont keep up with technical advances in
the field, and often resist informed suggestions about effective utilization of
resources.

Lets start with the common expression Crazy runs in families. This is true, but it
has been very difficult to clarify because a family tree peppered with psychoses
has so much variability by type, severity, and age of onset that their occurrence
can seem random or at least unrelated. Genome sequencing has identified
multiple loci for a spectrum of psychoses in which the specific whose combination
of genes, and their penetrance seem to explain those variations. At one end of
the spectrum is potential brilliance, the other hallucinatory divorce from reality.
Think of the phrase: Shes as pigheaded as her father. Doesnt it seem likely that
the balance between fast and slow is also coded into our genomes?

Postgraduate Medical Education

How has medicine coped traditionally with these unrecognized fast/slow issues?
Take a bunch of young people with good hearts and stellar academic records.
They have altruistic heuristics, learn well, and adapt to variability and chaos. This
is an ideal, new medical school class. They receive a progressive increase in
information over several years to nourish their slow systems. But, there is even
more emphasis on interactive topics, like taking a history. This can be viewed as a
way to mold the fast system for dealing, bonding, and gaining the trust of new
patients despite first impressions on both sides. It also creates an indelible bond
with our professional ancestors who have all had to cope with the same issue.
Medical specialty training expands upon integrating the two systems in some way.
I look back in awe, admiration, and fondness to my time as a diagnostic radiology
house officer at the Massachusetts General Hospital (MGH). I was probably not so
sanguine at the time. I presume the educational goals of all diagnostic radiology
training programs are identical everywhere. I have never had any need to inquire
of colleagues about their own background, because of the similarities of our
perceptions and work habits.

Reading plane films started out as a slow system endeavor. You try to look at
every detail of all of the views you have before you. Its very tiring, exhausting,
actually, and thats before you even start to integrate clinical information and
narrow down diagnostic possibilities. You keep hearing phrases like, get the
Gestalt without knowing what that means until, magically, you get it. There are
withering comments for errors, in public at conferences and more privately when
reviewing a board full of cases. There is scarcely anything positive for a good call.
It is much milder than the surgical experience. The system is geared toward
emergent decision making and directed towards avoiding errors, and if an error is
made, to be sure that it is not repeated.

The only way to handle a large volume of imaging studies efficiently is by


identifying any anomalies in any part of a film at a glance. The slow system does
not get evoked unless the fast system signals it needs to be activated. To do that
effectively, the fast system has to be able to cope with all kind of films, with
technical factors, including artefacts, and with a full range of normal variations.
The immediate correlates are anatomical; the inferences are pathophysiological.

Plainly, radiologists are marvelous, especially at radiology. Every specialist has


gone through a similar kind of education in their own fields, but because so much
of fast system training is not conscious, you cannot relate to alternate ways of
instant processing in other disciplines, even if they all share scientific foundations.
You may know the end result of someones clinical work, but not the way he or
she got there.

There has been a progressive ultrasound procedure drain from radiology into
other fields that have not had the years it takes for fast system retraining for
medical visual information work. It can succeed, but usually for specific questions
with simple yes and no kinds of answers. It obviates the general diagnostic utility
inherent in the method and the nature of its form of tissue mapping. The fast
system response of an unfortunate number of radiology departments to turf
issues seems to have been to relegate ultrasound to the cabinet of curiosities and
to move on in other imaging directions.

Interpreting Outside the Box

Articles about ultrasound without images are like desserts without carbs. If youre
like me youve already looked at the image. See anything interesting?

I selected an image from a recent visit to a level III NICU. Among ultrasounds
advantages is that high resolution, high contrast imaging can be performed in the
isolette without disturbing the endlessly fragile and vulnerable small premie.
Studies tend to be on demand when there is a suspicion of a problem. There are
often no baseline views for comparison or pre-emptive screening for early
diagnosis.

The renal image was from a female premie identified as a normal control,
without any other information provided. For the time being, go with this one view
and assume there were similar appearances for a few other papillae on both
sides, but nothing else. The fast system says: yellow alert, something unusual and
unexpected, presumptively pathological. There is also a vibe that the problem is
local and that its cause may have been a drug side effect. The slow system cannot
go much further without a lot more information, starting with why this child was
delivered early and whether there may have been hydramnios. Then, it will want
ALL of the available clinical information, and it may want to review what is known
about renal pathology in newborns. Are the image findings predictive of
nephrocalcinosis or predispose to papillary necrosis? Or will the appearance
revert to normal with the accelerated healing of fetuses and newborns? There is
not any available data to know the significance of the finding for renal
development in early childhood treatement or function in adolescence and
adulthood. There is a nice review of high resolution ultrasound of the pyramids
which raises the same concerns by A Daneman et al, Renal Pyramids: Focused
Sonosgraphy of Normal and Pathyologic Processes in Radiographics.
Prospect Theory

child dental x ray One of the main research areas of Thinking has to do with how
people make investments. What struck me was the framing of the concept with a
strong condition of loss aversion. The first aphorism of Hippocrates states
something like: Whatever you do, dont make things worse. Radiology has the
operative dicta: Do not miss anything in an image. Do not fail to provide
information to contribute to a therapeutic action plan. We are all really risk and
loss aversive.

Kahneman and Tversky found people faced with the same test problems may act
to gamble one time and not to another, depending on the way the problem is
phrased, as well as their moods and biases at the time. In addition, investors
decided to go for it or back off, depending on assessments of luck and
expectation of rewards. This is the fast system at work biased, not quantitative.
In our routine work, the equivalent might be the way an exam is conducted for a
happy situation like a normal pregnancy with a goal of wellness confirmation
versus the bleak scenario of staging an invasive carcinoma or searching for
metastases. Very busy work schedules, limited patient contact time, and overly
focused exam goals, promote reliance on habitual fast thinking.

I think of the alleged April Fools Day notion as witty product of someones fast
system. It has spread like a plague through a vulnerable population, insuring
commercial and administrative survival of ultrasound, but freezing progress or at
least dampening the urge to continually improve what we do. Consider this -
ultrasound and genetics are scientific contemporaries. On one side, we have
unlocked our genetic code. On the other, we are mired in qualitative fluid-solid
distinctions for a lot of what we do. It could be that is all we can contribute, but I
hope not. Its time we press our reset buttons and learn to invoke on our
collective slow systems for all of our clinical activities.
Social links
https://www.facebook.com/Image-Gently-
146714032030578/

https://twitter.com/ImageGently

Contact Us
General:
Donald Frush, MD
Professor of Radiology, Vice-Chair of Radiology
Duke University
Medical Center Department of Radiology Box 3808 DUMC
1905 Childrens Health Center
Durham, NC 27710
imagegently@aol.com

Keith Strauss, MSc


Assistant Professor
Cincinnati Childrens Hospital
University of Cincinnati School of Medicine
Department of Radiology, ML 5031
3333 Burnet Avenue
Cincinnati, OH 45229
imagegently@aol.com
Administration:
Jennifer Boylan
Executive Director - Society for Pediatric Radiology
1891 Preston White Drive
Reston, VA 20191
703-648-0681
jboylan@acr.org
Press:
Shawn Farley
Public Relations Manager
American College of Radiology
1891 Preston White Drive
Reston, VA 20191
(703) 648-8936 Office
(800) 227-5463 Ext. 4936
sfarley@acr.org
Medical Physics:
Keith J. Strauss, MSc
Cincinnati Childrens Hospital Medical Center
3333 Burnet Avenue ML 5031
Cincinnati, OH 45229
513-636-7775
Keith.Strauss@cchmc.org

Das könnte Ihnen auch gefallen