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medpundit |
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Saturday, September 21, 2002As a radiologist who still practices mammography, I know it is heresy to go against the American College of Radiology's recommendations and PR concerning mammography. But as a cycnical individual and a critical physician, I think any physician or individual with common sense who actually took the time to see the dilemma radiologists are in when reading mammograms would think we are absolutely crazy for still doing it. And more and more radiologists are opting not to, and very shortly, I may make that decision myself. I've been doing this now for almost 20 years since I began residency in 1983, and the expectations both from the professional side as well as the side of the patient are completely unreasonable. This is the only diagnostic modality where the positive findings we are expected to see, get smaller and more subtle as the years go on. The detection of microcalcifications is getting to the point where we are going to require microscopes to see the things we are being held responsible for. Even the computer aided detection systems out on the market miss many of these things. Our own published literature states that in women who have had annual yearly mammograms, and develop an interval breast cancer, that in up to 70% of the cases there will be some evidence of the cancer on the prior mammogram if you know where to look and exactly what to look for. Does this mean that we are all terrible at what we do? More likely, it's a problem with the modality expecting more from human perception than is reasonable. If you ask the NY Times however, they will tell you that the problem solely lies with the radiologist. In towns like Cleveland, in the midst of a litigation crisis, which by the way is where I used to work( for 15 years, another story) the lawyers know this. There are ads on the TV, that tell women who have had breast cancer detected on mammograms, that it is likely they are owed money and to bring their mammograms in to the lawyer's office for their own experts to review. The mammography litigation has skyrocketed. I believe as you alluded to that there is a problem not only with the radiology leadership on this issue letting its own people down, but I believe there is actually a somewhat more subtle, and sinister aspect. The people who provide guidance and determine the policy of the ACR on mammography stand to benefit tremendously financially. As recognized experts, they spend time writing books, which they sell, lecture all over the world for lots of money and travel time, and then make a lot of money as expert witnesses against the radiologists they teach, because they always have the power of hindsight behind them. I know this sounds very conspiratorial, and I'm really not that kind of individual, but in my own experience this seems to be true. As far as the patients are concerned, with mammography, sometimes we win and sometimes we lose. So, as this is presently the only available modality to find early breast cancer, it still has value. But it's extremely far from perfect as are the individuals stuck interpreting them. And you are absolutely right about ultrasound, this is even a worse trap as far as the false positive and false negative situation. One of our national experts, who does a great deal of defense work on the part of radiologists, has been quoted as saying, if you don't think there's anything there on the ultrasound, take no images and leave no record, because virtually anything on an ultrasound image can be construed as being potentially positive under the right circumstance. ADDENDUM: To get an idea of what radiologists are up against in interpreting mammograms, click here and scroll down to the third item. The image on the right is a mammogram of a dense breast. The one on the left is a normal breast. And here's an ultrasound image. It's easy to see why interpreting them isn't a perfect science. posted by Sydney on 9/21/2002 11:42:00 AM 0 comments 0 Comments: |
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