Patients-not just Images

Devoted to Education and Practice in Patient-centered Radiology

The Akash Fallacy

Ravi Ramakantan

Look carefully at the image below. Take a piece of paper and write down 'non-routine' sights that you see.

You are allowed only three words!

Akash fallacy radiology

Did you write it down?

We will get back to this.... at the end of this essay.

Meantime ....

The cat is easy enough to spot..

But, this 'strange' cat is friends with this dog and one follows the other.

Here is that 'known cat' again.

What will you look for?

Did you notice the paws of the dog in the image on the left? If not, go back and LOOK for it and you WILL see it (above the blue-green plastic bag - magnified in this image).

Now comes the real McCoy - The Akash Fallcy.

Akash was peeping over the shoulders of the radiology resident and staring at this image on the monitor. Smiling to myself, I asked "What do think is wrong with this ptient?' Doubly enthusiastic that someone thought it fit to ask for his radiological opinion, Akash correctly pointed to the coin in the neck.

Akash fallacy radiology
Akash fallacy radiology

And then even as I asked, "Anything else .. anything else", Akash firmly shook his head from side to side. But, a smart resident standing by - pointed to the 'rising moon' of another swallowed coin in the lower part of the same film above. Akash had been carried away by the obvious!

The second coin - the 'Peeping Tom' on the first image (above-right)

Akash is a ward-boy in our department - smart and intelligent and eager to learn. But, he has not been taught the basic rule in radiologic interpretation.

Ignore the obvious!

There is no rule in radiology that there can be only one pathology in one examination. Obvious though this may seem, one tends to forget that you can see many things on an image ; but, if you want to see ALL the things you have to LOOK for them. One way is to know the association of one pathology with the other and then it is easy... like our friends - the cat and dog!

So the next time, you see a 'solitary' pulmonary nodule on a chest CT, LOOK for more ; so too with MR of a tuberculous vertebra- these are , not infrequently, associated with 'skip' lesions.

There are NO short cuts, you have to give enough time at viewing each examination.

There are innumerable examples of this in everyday radiology and you will come across them again and gain. And then remember this story of Akash.

This attention to detail is what separates 'the merely competent amateur' from the 'very expert professional' and one tends to forget this - unless it is demonstrated repeatedly.

Now, back to our monkey!

Recall the Akash Fallacy, ignore the monkey and when you keep looking .. you will see something remarkable at the 4-5 O'clock position.

This magnified image shows it well.

And, there you are!

Of course you saw the monkey, even our young enthusiastic Akash, spotted it - but you are radiologist.. a very expert professional and you are taught and trained to keep looking.

So, have you learned from the Akah Fallacy?

Along with the monkey in the 5 O'clock position, the rich, colorful plumes of the peacock were there to see - all you need to do, is to look for - even the unexpected - and give time to each image.

Besides all this, tomorrow at your reporting console, remember to liberally use the magnification and windowing functions even for plain films.

More animals now...have you heard of the "Zebra Syndrome"?