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I’m going to let you in on a little secret.

I’m not a big fan of reading mammograms.

Xrayvsn that’s blasphemy!   You are a radiologist!   Aren’t you supposed love reading mammograms?

It’s true, as a radiologist, unless you are specialized in other areas, mammograms are part of a normal practice and constitute a decent percentage of your bread and butter cases.

Before we delve into why I chose the title for this particular post, I thought I would elaborate on why I, and probably a good portion of my brethren, feel this way about mammograms.

The Mammogram Dilemma.

A. Lack of a positive feedback loop.

Radiologists are human.

Things that get radiologists excited are those cool “teaching file” type cases that come across our displays and have you calling colleagues and discussing it in a fevered pitch.

[By the way, as a patient you never want to see a radiologist’s eyes light up when reviewing your study.  It’s not often a good sign.]

Imaging modalities such as CT and MRI are ripe with such imaging fruit and it helps to keep the day moving faster.

Mammograms?

Not so much.

As a radiologist, our jobs are to spot tiny groups of microcalcifications, smaller than the tip of a pin, and concerning nodules/architectural distortion.

The frequency of these findings makes them far less impactful for the radiologist’s psyche when compared to seeing a much rarer renal or brain tumor for example.

Given the fact that the vast majority of these mammogram findings on call back turn out to be benign also makes the radiologist feel like he or she hasn’t had as big an impact on patient care as with some other modalities.

Yes mammograms are incredibly important but they don’t have the flashy findings other modalities can present.

Financial tidbit:

Too often we find ourselves chasing the big score.

Whether it be individual stock picking, speculative positioning, etc, we can set ourselves up for disaster as these “home run” type investments are few and far between.

I recommend if you do want to swing for the fences, do so with money you can afford to lose (typically less than 3% of your net worth).

Investing for wealth should be boring which is the beauty for index investing.

B.  Litigious Factors.

Unfortunately reading mammograms increases the chance of a radiologist to get sued as the most cited reason for medical malpractice cases in radiology is a missed breast cancer diagnosis and the plaintiffs are typically awarded higher payouts.

Once a diagnosis of a breast cancer is made, it can be easy for the lawyer to go back in time and find older mammograms where you can then point to where the cancer originated from.

The radiologist is often put at a huge disadvantage in these instances.

The issue I have with this method of influencing the jurors is that what is easy to see retrospectively can be incredibly difficult to see prospectively.

Often there are multiple lesions seen in every breast.

It is just not feasible to work up every nodule with a diagnostic mammogram and/or biopsy.

So it is often a judgement call by the radiologist, who often uses time as his or her best friend to see if that lesion enlarges and needs more attention or not.

The problem occurs when a patient is lost to follow up and there are many years passed before the next mammogram occurs.

What would have been caught much earlier now presents as a much larger lesion which could then be traced back to a relatively innocuous area.

Financial tidbit:

Despite doing everything right, things still happen outside of your control.

Like malpractice insurance covering your financial interests in a medical lawsuit, it is important to insure yourself against other potential harmful situations.

C. The Visual Concentration Toll.

Mammograms are some of the most data intensive studies performed in a department.

Each mammogram is so densely packed with data that they can only be read on certain certified monitors with the appropriate resolution.

The absolute minimum required resolution for a monitor to be certified for mammography reading is a 5 megapixels (with many monitors having even higher resolution.)

This makes each display monitor jam packed with pixels.

And guess who has to scan each of those pixels to find those minuscule calcifications?

I often find my nose mere inches from the glass surface in order to feel confident in my microcalcification search.

This can lead so some very severe eyestrain and visual headaches if left unchecked.

To top it off looking for microcalcifications has a different visual requirement set than looking for the equally important suspicious nodules/architectural distortion.

Where as the former requires close up scrutiny for detection, the latter is better appreciated from a further distance.

A good analogy is to think of a photo mosaic.

If you are close to a photo mosaic you can appreciate the details of the individual pictures.

However if you do not step back you will never fully appreciate the overall appearance the way the artist intended.

 

This constant shifting between focal lengths as I scan a mammogram adds to the total visual strain.

Sure it can be tolerated for a study or two, but on a typical day when I am assigned to read mammograms (and X-rays and Ultrasounds), anywhere from 45-60 mammograms are waiting for my interpretation.

The mental toll adds up and I can’t wait til the end of the day so I can decompress.

Financial tidbit:

Sometimes we lose the forest for the trees in the world of finance.

Everyone may be fixated on trying to achieve the optimum asset allocation.

The truth is that it is the big picture that matters.

There are many well thought out asset allocations out there.

The main point is not to be bogged down in the minutiae and have paralysis by analysis and not invest at all.

Bad dog!

It is human nature for your eyes to automatically gravitate to something abnormal.

When I was in academics, I would ask the first year radiology residents what the most common missed fracture is.

After receiving a laundry list of various bones, I revealed the true answer, which is the second fracture.

When we see an obvious fracture on an X-ray, it is as if our brain shuts down and we do not process anything else.

This is a behavioral phenomenon known as “Satisfaction of Search.”

When I first open a mammogram, my eyes are immediately drawn to nodules.

Nodules are far easier to spot than microcalcifications so I would knock them out right off the bat by placing digital markers on these findings.

The problem is these markers are white.

Guess what else is white on mammograms?

Those pesky microcalcifications.

I thus was artificially creating extra visual tension as I was now looking for punctate white objects with distracting white markers all around which could potentially reduce its conspicuity.

Another habit I had to change was how I analyzed each image.

For years I had scanned a mammogram from top to bottom, line by line (much like one of those old time dot matrix printers) looking for both microcalcifications and nodules at the same time.

I thought this was the most efficient way possible.

Boy was I wrong.

It is quite appropriate that earlier I used changing focal lengths as a cause for visual strain.

This allows me to use the following analogy when showcasing how my traditional method of trying to evaluate both nodules and calcifications in one pass was not the most efficient way.

For those photographers out there with an SLR style camera, it is akin to having to constantly alternate between a macro lens and a regular lens for each shot.

It is much more efficient to get all the shots requiring the one lens before detaching and switching to the other.

I thus came to an epiphany of analyzing the image first for microcalcifications and then re-scanning that exact same image again for nodules.

Looking for microcalcifications first eliminated the white marker distractors from my nodule markings and obviated the need for me to mentally eliminate them as I had done in my traditional method.

That freed up some precious mental bandwidth.

The second pass through each mammogram was much faster as well as I now was able to scan globally each breast at a more comfortable distance.

Financial tidbit:

1. No matter how long you have been doing something, it pays to keep striving to make it more efficient or be open to new methods for improvement.

A lot of us set things on auto payment and forget about it.

Subscriptions and services we no longer need continue to drain our wallet because we forget about it and maintain the status quo.

Often we stay with the same insurance company or bank for years or even decades because we are too lazy to try new things and perhaps get a potential financial discount or bonus.

2.  Too often we gravitate to the easy things and leave the harder items for later.

However if you front-load the effort, you can often reap the rewards for this effort later.

This is the founding principle for building a passive income empire which requires up front sacrifice for later benefits.

Re-training This Old Dog.

Having read 1000s upon 1000s of mammograms in my 16 year career as an attending, old habits die hard.

My epiphany of the 2 pass method of mammogram reading just so happened to be on the last day of my mammogram rotation (every other week).

A week later, on the first day back on the mammogram schedule, I had 3/4 schedule finished before I realized I had been reading mammograms the traditional inefficient way.

I also found out that when the s&@t hits the fan and I am swamped with studies coming in all at once I tended to revert back to my old habits.

In fact these ingrained habits were so hard to break that I ended up whispering to myself in a song like fashion each step I was trying to enact with my new reading method until it became routine.

This “ritualization” finally took hold and the two pass mammogram reading method has now become the norm.

I am happy to say that these subtle tweaks to my mammogram reading habits has produced dramatic changes in my well-being.

Financial tidbit:

Chaotic situations seem to cause individuals to revert to their default bad habits.

Many mistakes are made by investors due to emotional swings caused by large gains or losses in the stock market.

Panic selling/buying is the quickest way to transfer your wealth to someone else.

It is important to follow the ritual you have set up, in this case a written Investor Policy Statement.

 

Note:

If you are in search of financial help, please consider enlisting the service of any of the sponsors of this blog who I feel are part of the “good guys and gals of finance.”

Even a steadfast DIY’er can sometimes gain benefit from the occasional professional input.

 

 

-Xrayvsn