BELIEVING IS SEEING


My wife read a CT Scan of the heart recently, done to check coronary artery calcification, and told the referring physician the patient had breast cancer.

Whoa!  What does that have to do with heart disease?  The answer: nothing, and that is the point: we need radiologists to read films formally and not clinicians, and I say that as a former clinician who read CT head scans really well.  It’s fine for a medical group to have its own X-Ray facility and for clinicians to read the images.  But every image must have a formal reading by a radiologist, for that individual is both unbiased and trained to look at everything on the image, every corner, every part.  There is no law in nature that says a person will have one thing wrong.  It is entirely possible for a neurologist to look at an MRI of the spine and miss a large abdominal aortic aneurysm.  We see what we expect to see.  Seeing isn’t believing.  Believing is seeing.  We believe something, and we tend to look for it.

On a CT scan, there is a side view, which shows the skin.  This isn’t a mammogram, but it certainly is capable of showing a breast cancer.  In addition to the breast cancer, there was a “ground glass” area in the lung suggesting there might be an early lung cancer, too.  Wow. A CT scan of the heart is done for coronary disease, and two other systems have primary cancers.  Maybe the cardiologist would have found those, but I doubt it.  I doubt when I read CT scans of the head that I would have found a throat cancer, even though the throat was scanned and on the film.

In my defense, I was once sent a patient with leg pain, with a concern that this was due to pinched nerve in the back.  The lady had pain near the knee, but it was point tender, and I obtained a bone scan, looking for a fracture.  I found a hairline fracture of the proximal  tibia.  I got a lot of pleasure diagnosing something correctly out of my field.  Most specialists do.  There is a cardiologist in town, whom I met 31 years ago when he was new here.  I had seen a man in the emergency department who had driven 2500 km to Arizona and presented with sudden, brief unconsciousness.  I saw him and noted he seemed to be breathing a little faster than normal.  I obtained an arterial blood gas and found pronounced hypoxia.  Thinking that a cardiac arrhythmia would cause unconsciousness (strokes seldom do), and thinking of pulmonary emboli as a cause of both that and hypoxia, I did a lung scan, since that is what we did back then, and there were pulmonary emboli, because of leg clots that occurred during prolonged sitting on his drive to Arizona from Minnesota.  The cardiologist happened to be present, and I referred the patient to him.

Several years later, one of that cardiologist’s partners referred a patient to me on whom he had diagnosed an occipital lobe infarct.  For a neurologist, that is not difficult, but I was impressed the cardiologist had picked it up.  Most non-neurologists miss it.

So when the MRI of my neck was unchanged from 9 years ago, that was good news, I was a bit chagrined, however, when the radiologist told me that I had a significant thyroid nodule.  It never occurred to me look for thyroid disease on my MRI.  It is sort of like people’s being surprised when I tell them the Moon is visible in broad daylight.  “It is?” they say.

“It’s there, isn’t it?”  I reply.  The thyroid nodule was quite present.  Once I looked, there it was, plain as can be, like the first quarter Moon in the southeastern sky in the afternoon.  Try finding the Moon in daylight, sometime, if you haven’t seen it.  You will discover a whole new world–literally., and wonder why you never noticed it before.  That’s the problem.  We notice only what we are willing to notice.  Once we are willing to notice many things, a brand new world opens up to us.  Like the Moon, or even Venus, which you can often see in broad daylight, if you know where to look.

Look around you.  See, smell, touch, hear, and taste the world.  Notice things.  Life becomes very interesting when you do.

Even when you have an “interesting” thyroid nodule.  By the way, it was benign.

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