2 articles of interest - Are more heads better than one?

Parkash, Vinita vinita.parkash at YALE.EDU
Mon Mar 4 02:34:16 UTC 2019

Dear All,
Double review is performed frequently in pathology. Most practices have requirements for double reads on a subset/type of cases.

But as with everything else, it has to be done right.

Double reads definitely improve detection of oversight/perceptual errors (“I missed that” / “didn’t see it”). But since it has to be for all cases (we are looking for misses) the yield is extremely low for the effort and expense. AI might be very useful here as a screening tool.

For interpretive/cognitive errors double reads (“saw it but decided on another diagnosis, because of weighting/knowledge etc”), the structure needs to be right. The second review has to be independent, blinded and performed by a person of equal or higher competency, in an atmosphere of psychological safety. Without that these diagnoses are subject to framing, group-think, social loafing and “big dog” effects—same goes for CPC’s and multidisciplinary tumor board also.

Multiple review has another problem that to my knowledge has not gotten enough attention. My data suggest an apparent increase in ambiguous diagnoses with increased recommendations for repeat or additional testing. I say white, you say black.. we can agree on grey. Let’s do another biopsy. A diagnosis of uncertainty when there should have been certainty is as wrong as a diagnosis of certainty when there should have one of uncertainty.

Yale School of Medicine; Yale School of Public Health
From: Leonard Berlin <lberlin at LIVE.COM>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, Leonard Berlin <lberlin at LIVE.COM>
Date: Sunday, March 3, 2019 at 8:48 PM
Subject: Re: [IMPROVEDX] 2 articles of interest - Are more heads better than one?

Dear Rob (whom I only know by name, but a friend anyway), and my good friends Mike and Kimberly:

Mike's article highlighting double reading refers to interpretations by residents vs interpretations by experienced staff radiologists.  In that  situation the overread makes sense and is probably necessary.  As for addendums placed on interpretations that had been made and now when another radiologist sees something different as mentioned by Kimberly, then the addendum is probably necessary. But that doesn't occur often and is not a routine situation.

Much has been written regarding routine double-reading in the US literature, and it's almost universal that American radiologists have spoken against doing it.  It's time-consuming and expensive to say the least, but consider the following scenario:
Rob orders an abdominal CT on a patient: radiologist 1 concludes that the findings indicate ABC; but a second reader (radiologist 2)  who is routinely called, concludes that the findings are XYZ.  So now a third radiologist-umpire is called to settle the difference: he agrees with rad 1, but disagrees with rad 2.There's no time to call a 4th radiologist, so Rob gets a report that concludes that "by a 2 to 1 margin, the findings are ABC."

I'm sure Rob would be really comfortable and well assured with a conclusion such as that!

On a more serious view, double reading is routinely done in a few European nations, mainly Norway.  Articles written by them indicate that they do find and correct some errors in up to 10% of cases; however, whether the health of a significant number of patients improve as a result of routine double reading is vague at best.

As we all know, volume of radiologic studies, especially CTs and MRIs, has been increasing tremendously.  Radiologists are unfortunately reading faster in order to keep up; taking time for a routine overread for every case is truly impossible, and of questionable value.

AI (artificial intelligence) may bring something new, indeed. However, how about Kimberly, or Mike, or myself, reads a C, then having it checked by a robot.  But the robot disagrees; so another robot is called and it disagrees with the first robot.  What do we do then??

Stay tuned....,....

Best to all,  😊  😢 😈


Leonard Berlin, MD, FACR

PS: Kimberly and Mike, I'll be speaking about discrepancies, errors, and double reading at the ARRS Annual Meeting beginning May 5.  I don't know yet whether the ARRS leadership will have a second radiologist over-lecture   my lecture, and if they decide to do so, what will happen if the second radiologist disagrees with me ?
Perhaps Kimberly or Mike can be the umpire!



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