The Common Vein

How radiologists or any clinician
pursuing a diagnosis are like
detectives

• Start with Curiosity

  • 1- Gather Information

  • 2- Notes Scales and Music Approach

    • Notes

      • Where to look  Not Invisible but Unnoticed

        • Structures to be evaluated

    • Scales

      • How to look

        • Apply a consistent method to evaluate the structures

    • Music
      • What to look for  
      • The art and talent of detection
        • Anticipate where to look
        • Integrate knowledge experience and acquired clues with sequential thinking as the story builds and the problem is solved

 

• • Sherlock Holmes ? approach a case with a blank mind

• Detective Problem

  • Somebody has been Murdered

  • 

  • How do you approach?

    • • • Start with Curiosity

          • 1- Gather Information

          • What is known of the

            • History of the murdered person

              • Prior history that is available – public records etc

              • Relationships

              • When last seen alive

          • 2- Notes Scales and Music Approach

            • Notes

            • • Where to look

                • Structures to be evaluated

            • Scales

            • • • How to look

                  • Apply a consistent method to evaluate the structures

                    • Structural components of the murder scene
                      • Physical Exam of the Victim
                      • Most immediate surrounds and
                      • making your way  to the expanding environment
            • Music
              • What to look for
                • The art and talent of detection
                  • Anticipate where to look and what to look for
                    • Integrate knowledge experience and acquired clues with sequential thinking as the story builds and the problem is solved

    • Notes – Anatomy = physical environment of the crime scene

      • The victim

      • The  surrounds 

    • Scales – Method of looking

      •  The Victim
        • Like a Clinical Exam – have a smooth spatially logical way of evaluating the victim
      • The Surrounds
        • Have a fluid method that has logical sense
          • immediate surrounds of the victim
          • progressive spatial  spaces around the victim
    • Music – Game time –
      • time to bring observations knowledge memory, experience together in an attempt to solve the problem

        Radiology/Diagnostic Problem –

        • • Is there is a disease on the loose?
            Approach with curiosity

          • Notes Scales and Music

• 

• Start with Curiosity

  • 1- Gather Information

  • What is known of the medical history of the patient

    Prior medical istory that is available – Epic

  • Prior Radiologic history from prior radiology reports

  • 2- Notes Scales and Music Approach

    • Notes

      • Where to look

        • Structures to be evaluated

    • Scales

      How to look

      • Apply a consistent method to evaluate the structures

        • Structural components of the image
          • The search pattern
    • Music
      • What to look for
        • The art and talent of detection
          • Anticipate where to look and what to look for
            • Integrate knowledge experience and acquired clues with sequential thinking as the story builds and the problem is solved
• An Example

• 

• Approach with curiosity

  • • • Gather information before the hunt for clues

        1st clue – Patient History

        • Patient with Chest Pain and history of SLE
          • art of sequential thinking
            • start by pausing with each clue
            • chest pain
              • start using sequential thinking
              • anatomical differential diagnosis as a cause for chest pain
              • eg  central structures to peripheral structures
              • (create a fluid method for yourself that makes sense
                • heart /pericardium/pleura esophagus/muscle bone
                • SLE
                • in to out
                • heart (premature atherosclerosis) pericardium (pericarditis)pleura (serositis PE) esophagus eg mixed collagen disease scleroderma reflux) bone (trauma) muscle (myalgia trauma)
              • Have to integrate
                • knowledge  (which we feed you in med school and you feed yourself with curiosity)
                • memory ( need to have ways for improving memory)
                • experience
            • Once you have your clues you
            • Lesson  from  Sherlock Holmes –
              • Not Invisible but Unnoticed
              • ie anticipating where to look
        • • Background to the patient
            • (equivalent to previous studies or radiographic history)
              • again as new evidence of the person builds
                • continue to practice curiosity and sequential thinking
                  • connecting with memory knowledge experience
                    • eg history SLE in a 45 year old female
                      • eg heart – pericarditis pulmonary hypertension Libman Sacks vegetation premature atherosclerotic heart disease
                        • ie remember to look at the coronary arteries,
                        • pleural effusions and serositis,
                        • ILD and a
                        • repeated wisdom from  Sherlock Holmes –Imaging
                          • Not Invisible but Unknown –
                            • anticipating where to look
• Notes
  • Anatomy Where to look
• Scales
  • How to Look
• Music
  • Game Time
    • • • • • • • Selecting what finding is relevant to the problem
                  • Sherlock Holmes What was vital was overlaid and hidden
    • Game time and the Search Pattern
      • Create a logical, spatially connected ,smooth/fluid/flowing order of how to look at an image
        •  Notes Scales and Music
  • What catches your eye
    • what stands out as an
      • abnormality or the
      • criminal
        • Sherlock Holmes -Not Invisible but Unknown
    • Sometimes it is obvious sometimes experience is needed
      • knowledge of “normal” specifically parts/size/shape/position/character/changes with time/bonds
        • eg blood vessels, nerves veins ducts, lymphatics
        • See Applied Anatomy big project  but shows how principles of structure apply to imaging
      • when a finding is not obvious
        • Sherlock Holmes Crime is common ? logic is rare
        • Sherlock Holmes What was vital was overlaid and hidden
  • Analysis
    • Parts/Size/Shape/Position/Character/Time/Bonds
    • Thumbs Up Thumbs Down or Somewhere in Between
      • Link associated findings
      • Principles of Imaging Structure 
        • Structural Analysis
  • Discussion
    • Gathering thoughts and thinking about the case
      • Sherlock Holmes recognize which are incidental and which vital
      • Sherlock Holmes ? reasoning and deduction
      • Sherlock Holmes Crime is common ? logic is rare
      • Sherlock Holmes Curiosity and the Mundane
      • Sherlock Holmes Facts First then Creativity and Speculation
      • Sherlock Holmes Solitude and Introspection to Solve for Complex Problems

 

• Links and References

  • TCV
    • Sherlock Holmes Quotes
    • RnD Map