Patients-not just Images

Devoted to Education and Practice in Patient-centered Radiology

Stop The Spot !

Ravi Ramakantan

After 35 years of being a teacher for postgraduate Radiology courses, I have come to know that success or failure at the post graduate examinations in Radiology as it is practiced today, is very much dependant on how a student fares in the "Spots"

And, what are these hallowed spots?

Every candidate is expected to go through several images – typically about 40 – in as many minutes and make a diagnosis. Depending on whether the examiners are 'benign or malignant creatures, the spots may be easy, difficult, or even impossible ones. Not even a single word of the clinical background of the case is ever given.

Now, we come to the interesting part – how are these spots chosen by the examiners?

Each examiner has a coveted collection of key spots that he or she brings along to the exam.

Usually, the chief examiner gets to show the bulk of the spots with a spattering of films from the other examiners.

In being a supervisor at these examinations, on several occasions, I have gotten to see the innards of the practical examinations and I have never seen examiners honestly look at the spots from their co-examiners and see if they can themselves make the diagnosis in under 1 min.

Hilarious though it may seem,, I have seen this happening many times. While choosing the 'final spots' to be shown to the candidates, one examiner may show a spot of his to the co-examiners. Typically, when this happens, the response from the other examiner/s is:

"What a beautiful case,, I have never seen anything like this before" or "nice picture".. "Great, what was the diagnosis?" or some such.

Surely, this is not what happens all the time. But, only rarely have I seen co-examiners even attempting to 'spot the diagnosis each others spots' in under one minute without any clinical story. I am saying this with no sense of ridicule of the examiners. Perhaps, they are just captives of an entrenched system of examinations the world over.

Obviously, we are in unfair territory here.

But where are the alternatives –many have a asked me?

As a matter of fact, it would be very simple to find solutions to this issue if the powers that be huddle in a conference and find out simple solutions to this apparently complex problem . For example, instead of spots, there could be multiple short cases in which there is a discussion between the examiner and the examinee.

And finally, God forbid, if spots are to remain an integral part of all examinations, let me suggest the following method for scoring the candidates.

In an impartial environment, the examiners should look at the spots from co-examiners in under 1 minute and they are scored on this. The total of marks that each of the examiners gets – on the other examiners spots is averaged for all four examiners and that should be considered as hundred percent marks. That, I feel, would be a good way to salvage a bad situation.

But, we are going away from the main point of this article.

What I'm saying is that in real life radiology, there is never ever a situation where you have to make a diagnosis on a single film in under one minute without any clinical information - unless one is a security staff in an airport baggage belt.

Photo credit Hindustan Times

In Real-life Radiology-you see, contemplate, discuss and decide because...

.... the patient and the anxious family are waiting for you.

(displayed with permission)

And finally, if you have been an university teacher in radiology, when was the last time YOU talked to a patient about the history or the examination findings or explained to a patient before or after a diagnostic radiological examination?

When was the last time you lead by example?

In 1989, in an editorial in the Indian Journal of Radiology and Imaging, I had said "Stop the Spot" . Nothing seems to have changed in the last 30 years.

So, here again is my - shouting from the rooftop - call about postgraduate radiology examinations.

Stop the Spot

And if you don't, in the next few years, intelligent machines will make all the qualified spotters redundant and then it would have been too late.