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Chairman's Corner
Chairman's Corner
“Even Pinheads Come in Different Sizes”
“Even Pinheads Come in Different Sizes”
Ravi Ramakantan
Ravi Ramakantan
The title of this essay is a throwback to a footnote in Hamilton Bailey's textbook : “Demonstrations of Physical Signs in Clinical Surgery” .
The title of this essay is a throwback to a footnote in Hamilton Bailey's textbook : “Demonstrations of Physical Signs in Clinical Surgery” .
As a medical student, I would constantly refer to this book.. also for its footnotes. Deploring the unscientific attitude of physicians in describing lesions as “cricket ball sized” or “lemon sized” or “the size of a pinhead”, he had said -
As a medical student, I would constantly refer to this book.. also for its footnotes. Deploring the unscientific attitude of physicians in describing lesions as “cricket ball sized” or “lemon sized” or “the size of a pinhead”, he had said -
“Even pinheads come in different sizes”
“Even pinheads come in different sizes”
He strongly believed that any ‘lesion’ that can be measured reasonably easily should be described in centimetres, inches etc. I just loved that statement and even today, recall it when my residents describe a lesion as a ‘large mass’.
He strongly believed that any ‘lesion’ that can be measured reasonably easily should be described in centimetres, inches etc. I just loved that statement and even today, recall it when my residents describe a lesion as a ‘large mass’.
Radiology measurements start on “First Day , First show” - the ubiquitous, Cardiothoracic ratio. (CTR)
Radiology measurements start on “First Day , First show” - the ubiquitous, Cardiothoracic ratio. (CTR)
I have no problems with that - after all, it is a ratio - nothing absolute about it.
I have no problems with that - after all, it is a ratio - nothing absolute about it.
Thankfully, except in their first year of residency, or perhaps in their examination, one rarely sees residents measuring the CTR with a ruler or in digital images - with a cursor on the monitor.
Thankfully, except in their first year of residency, or perhaps in their examination, one rarely sees residents measuring the CTR with a ruler or in digital images - with a cursor on the monitor.
The trouble starts when one ventures into cross sectional imaging.
The trouble starts when one ventures into cross sectional imaging.
Ultrasound, CT and MRI reports are replete with … measurements
Ultrasound, CT and MRI reports are replete with … measurements
6.51 x 4.42 x 2.23 cm stuff. Thank God, they have not progressed to the thousandth place!
6.51 x 4.42 x 2.23 cm stuff. Thank God, they have not progressed to the thousandth place!
After so many decades of these - correct to a tenth of a millimeter - measurements on radiology reports , I still ‘forehead my hand’ with a “Ayyo Rama” when I see such mindlessness.
After so many decades of these - correct to a tenth of a millimeter - measurements on radiology reports , I still ‘forehead my hand’ with a “Ayyo Rama” when I see such mindlessness.
Recently, I learnt of a beautiful quote from Abraham Maslow :
Recently, I learnt of a beautiful quote from Abraham Maslow :
“If all you have is a hammer, everything looks like a nail”.
“If all you have is a hammer, everything looks like a nail”.
How about, “To the cursor born, life is cursed with fractions of a millimeter”
How about, “To the cursor born, life is cursed with fractions of a millimeter”
But, first.. back to the past.
But, first.. back to the past.
There was a time in the the 1980s, when I would proudly trot around with a small Rs.15 stainless steel ruler in my shirt pocket.
There was a time in the the 1980s, when I would proudly trot around with a small Rs.15 stainless steel ruler in my shirt pocket.
It was my constant companion.. In fact I thought it was so important that once I went to that stationery shop and ordered a full dozen of them and gave one to each resident - expecting that everything that was measurable would be measured.
It was my constant companion.. In fact I thought it was so important that once I went to that stationery shop and ordered a full dozen of them and gave one to each resident - expecting that everything that was measurable would be measured.
Life rolled by, I grew older and and wiser - it turned out that each time I felt the need to actually measure something with a ruler, that measurement fell in the “may be normal.. may be abnormal” range.
Life rolled by, I grew older and and wiser - it turned out that each time I felt the need to actually measure something with a ruler, that measurement fell in the “may be normal.. may be abnormal” range.
After a few years of this unfailing ‘success’ with such “may be .. may not be” measurements, one hot summer evening, I went to the Mahim bay and ceremoniously parted with that Rs.15 ruler in the waters of the Arabian Sea.
After a few years of this unfailing ‘success’ with such “may be .. may not be” measurements, one hot summer evening, I went to the Mahim bay and ceremoniously parted with that Rs.15 ruler in the waters of the Arabian Sea.
And then was born: ‘Radiology Ravi’s Ruler Rule’ that goes something along these lines:
And then was born: ‘Radiology Ravi’s Ruler Rule’ that goes something along these lines:
“After 3 years in Radiology, if your eyes are not sure if something is normal sized or larger or smaller on a radiograph, do not measure with a ruler; because, that measurement will always fall in the borderland between normal and abnormal”.
“After 3 years in Radiology, if your eyes are not sure if something is normal sized or larger or smaller on a radiograph, do not measure with a ruler; because, that measurement will always fall in the borderland between normal and abnormal”.
Dear bacchus,
Dear bacchus,
I hope you did not part with your ‘thinking brains’ when you trained for your “tick where applicable” 110/100 MCQ entrance exams.
I hope you did not part with your ‘thinking brains’ when you trained for your “tick where applicable” 110/100 MCQ entrance exams.
Surely, you realise that human beings are not born nor grow up - correct to a hundredth of a millimeter or for that matter even a metre.
Surely, you realise that human beings are not born nor grow up - correct to a hundredth of a millimeter or for that matter even a metre.
Remember the day when you went to the readymade garment shop and purchased a ‘S’ size T shirt and your friend looked puzzled “should I buy “M, L, XL, XXL” size?.
Remember the day when you went to the readymade garment shop and purchased a ‘S’ size T shirt and your friend looked puzzled “should I buy “M, L, XL, XXL” size?.
Do you remember your medical residency days when you used a No.6 sized glove and your boss a No. 71/2 glove and the No. 8 glove was too small for his ‘Caucasian hands’ of the visiting interventional radiologist?
Do you remember your medical residency days when you used a No.6 sized glove and your boss a No. 71/2 glove and the No. 8 glove was too small for his ‘Caucasian hands’ of the visiting interventional radiologist?
Human beings are not made to order - they come in all sizes..
Human beings are not made to order - they come in all sizes..
So do their kidneys, livers, ovaries, hippocampus and so on.
So do their kidneys, livers, ovaries, hippocampus and so on.
Therefore, on the infrequent occasion that I see cross sectional images , I look at the ‘ruler’ on the side of the image and guess normal and abnormal.
Therefore, on the infrequent occasion that I see cross sectional images , I look at the ‘ruler’ on the side of the image and guess normal and abnormal.
Surely, in rare exceptions, where long-term follow-up is necessary, you could use a cursor and electronic scale for ‘accurate’ measurement.
Surely, in rare exceptions, where long-term follow-up is necessary, you could use a cursor and electronic scale for ‘accurate’ measurement.
The story of how accurate these ‘accurate’ measurements are and how they vary between different observers and with the same observer before and after breakfast, and between Friday evenings and Monday mornings will have to wait for another Chairman's Corner!
The story of how accurate these ‘accurate’ measurements are and how they vary between different observers and with the same observer before and after breakfast, and between Friday evenings and Monday mornings will have to wait for another Chairman's Corner!
More than all this, almost all of these ‘‘holy’, so called normal ranges we use are from Western data.
More than all this, almost all of these ‘‘holy’, so called normal ranges we use are from Western data.
I never tire of saying
I never tire of saying
“Indians are not 6 feet tall, do not have blue eyes and blonde hair”
“Indians are not 6 feet tall, do not have blue eyes and blonde hair”
Blindly relying on Western measurements correct to a fraction of a millimeter in our reports is - at the very least - being bird brained,.
Blindly relying on Western measurements correct to a fraction of a millimeter in our reports is - at the very least - being bird brained,.
If you do not believe me, see data from this research .
If you do not believe me, see data from this research .
You have a lifetime ahead of you. It should not be a difficult task for all of you put your thinking brains together and start establishing ‘normals’ for everything Indian. We missed that bus - you need not.
You have a lifetime ahead of you. It should not be a difficult task for all of you put your thinking brains together and start establishing ‘normals’ for everything Indian. We missed that bus - you need not.
Then, perhaps, you can go back to the infamous “6.66 x 3.33 x 4.44 “ cm reports.
Then, perhaps, you can go back to the infamous “6.66 x 3.33 x 4.44 “ cm reports.
That would be some progress.
That would be some progress.
Pinheads do come in different sizes ; but, no one goes around measuring them!
Pinheads do come in different sizes ; but, no one goes around measuring them!
December 2018
December 2018
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