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Point: A Missed Lung Nodule Is a Significant Miss
POINT/COUNTERPOINT
Counterpoint: A Missed Lung Nodule Is a Significant Miss Richard E. Heller III, MD, MBA Size matters not. —Yoda
A missed lung nodule is a significant miss. Dr Jha proposed this subject for debate, but I would suggest a modest rephrasing: The adjective significant should also modify the noun nodule, not just the word miss. A missed significant lung nodule is a significant miss. This is an important distinction because I will concede here in the opening paragraph that not all nodules are significant and omitting these in the report does not constitute a significant error. Some context: Dr Jha was explaining to me that at his institution, when a resident makes an error, be it a missed aortic dissection or an unmentioned pulmonary nodule, it gets logged as an error without differentiation. He disagrees with this, contending the misses are not equivalent. I understand Dr Jha’s position. Some mistakes are more egregious than others. For example, contrary to what Star Wars character Yoda has to say, sometimes (often) size does matter. Missing a 10-cm renal mass is more serious than missing a 1-cm mass. The larger mass is more obvious and more likely to be clinically relevant. The same applies for a larger (or “significant”) lung nodule.
Given his sentiment, I suspect Dr Jha is contrasting a resident missing an obvious aortic dissection with an unmentioned, isolated, and incidental 2-mm lung nodule. I will grant that, in that case, only the dissection is a significant error. But what about the missed chronic Type-B dissection versus an unmentioned 2.5-cm spiculated lung nodule? Which of these is more meaningful? I contend they both qualify as significant errors. My point is not that all errors are equal; rather, my point is that from an educational perspective, all errors of clinical significance can be put into a single bucket that I call “stuff you should not miss.” And a significant pulmonary nodule falls into the category of stuff you should not miss. Does an aortic dissection qualify too? Sure. It is a big category. What defines a “significant” pulmonary nodule? I agree that missing the incidental 2-mm nodule should not be logged in the resident’s “book of shame” (what we called it in residency). But I bet that most of us would ding a resident for overlooking a 2-cm nodule. So, where to draw the line? I like the guideline that if catching the omission necessitates an addendum, it is a significant error. Using this construct, if a missed lung nodule
ª 2017 American College of Radiology 1546-1440/17/$36.00 n http://dx.doi.org/10.1016/j.jacr.2017.06.029
should be mentioned because it has clinical implications (ie, it should be followed by Fleischner Society criteria), then I would consider it a significant miss. The point of the attending resident readout is 2-fold: patient care and trainee education. From the patient care perspective, I acknowledge that there are two categories of clinically significant errors. Some entities are likely to kill the patient immediately, whereas others may not cause harm for months or years. From the patient care perspective, this is a meaningful difference. For example. I need to call the emergency department right now for the missed tension pneumothorax, but I can wait till after readout to mention the suspicious colonic mass. From the educational perspective, however, these differences are meaningless. They all fall under the category of “stuff you should not miss.” In residency, I kept a list of every meaningful error I made, in an attempt (sometimes in vain) to ensure that I did not make the same mistake again. I did not keep two lists—one for acute pathology and a second for pathology that would take months or even years to become clinically evident. When I reviewed the (admittedly lengthy) list, I made sure I was comfortable with everything. My thinking was that I
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should not miss any of the entities, from a patient care perspective, a board examination perspective, or a medical-legal perspective. Missing the significant lung nodule that ends up being lung cancer can cause just as much trouble as missing the aortic dissection.
I conclude with two points. First, although I admit that lung nodules as a category are rather plebian, identifying and commenting on significant findings is our job. So, although I would not put a resident in the book of shame for missing the 2-mm ditzel,
not mentioning a significant lung nodule is a significant miss. Second, I have some advice for residents: Keep a single list of all meaningful errors you make. Unless you happen to be reading out with Dr Jha; in that case, consider having multiple lists.
The author has no conflicts of interest related to the material discussed in this article. Richard E. Heller III, MD, MBA: Radiology Partners, 2101 E El Segundo Blvd, Suite 401, El Segundo, CA 90245; e-mail: richard. [email protected].
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Journal of the American College of Radiology Volume - n Number - n - 2017
Counterpoint: A Missed Lung Nodule Is a Significant Miss Richard E. Heller III, MD, MBA Size matters not. —Yoda
A missed lung nodule is a significant miss. Dr Jha proposed this subject for debate, but I would suggest a modest rephrasing: The adjective significant should also modify the noun nodule, not just the word miss. A missed significant lung nodule is a significant miss. This is an important distinction because I will concede here in the opening paragraph that not all nodules are significant and omitting these in the report does not constitute a significant error. Some context: Dr Jha was explaining to me that at his institution, when a resident makes an error, be it a missed aortic dissection or an unmentioned pulmonary nodule, it gets logged as an error without differentiation. He disagrees with this, contending the misses are not equivalent. I understand Dr Jha’s position. Some mistakes are more egregious than others. For example, contrary to what Star Wars character Yoda has to say, sometimes (often) size does matter. Missing a 10-cm renal mass is more serious than missing a 1-cm mass. The larger mass is more obvious and more likely to be clinically relevant. The same applies for a larger (or “significant”) lung nodule.
Given his sentiment, I suspect Dr Jha is contrasting a resident missing an obvious aortic dissection with an unmentioned, isolated, and incidental 2-mm lung nodule. I will grant that, in that case, only the dissection is a significant error. But what about the missed chronic Type-B dissection versus an unmentioned 2.5-cm spiculated lung nodule? Which of these is more meaningful? I contend they both qualify as significant errors. My point is not that all errors are equal; rather, my point is that from an educational perspective, all errors of clinical significance can be put into a single bucket that I call “stuff you should not miss.” And a significant pulmonary nodule falls into the category of stuff you should not miss. Does an aortic dissection qualify too? Sure. It is a big category. What defines a “significant” pulmonary nodule? I agree that missing the incidental 2-mm nodule should not be logged in the resident’s “book of shame” (what we called it in residency). But I bet that most of us would ding a resident for overlooking a 2-cm nodule. So, where to draw the line? I like the guideline that if catching the omission necessitates an addendum, it is a significant error. Using this construct, if a missed lung nodule
ª 2017 American College of Radiology 1546-1440/17/$36.00 n http://dx.doi.org/10.1016/j.jacr.2017.06.029
should be mentioned because it has clinical implications (ie, it should be followed by Fleischner Society criteria), then I would consider it a significant miss. The point of the attending resident readout is 2-fold: patient care and trainee education. From the patient care perspective, I acknowledge that there are two categories of clinically significant errors. Some entities are likely to kill the patient immediately, whereas others may not cause harm for months or years. From the patient care perspective, this is a meaningful difference. For example. I need to call the emergency department right now for the missed tension pneumothorax, but I can wait till after readout to mention the suspicious colonic mass. From the educational perspective, however, these differences are meaningless. They all fall under the category of “stuff you should not miss.” In residency, I kept a list of every meaningful error I made, in an attempt (sometimes in vain) to ensure that I did not make the same mistake again. I did not keep two lists—one for acute pathology and a second for pathology that would take months or even years to become clinically evident. When I reviewed the (admittedly lengthy) list, I made sure I was comfortable with everything. My thinking was that I
1
should not miss any of the entities, from a patient care perspective, a board examination perspective, or a medical-legal perspective. Missing the significant lung nodule that ends up being lung cancer can cause just as much trouble as missing the aortic dissection.
I conclude with two points. First, although I admit that lung nodules as a category are rather plebian, identifying and commenting on significant findings is our job. So, although I would not put a resident in the book of shame for missing the 2-mm ditzel,
not mentioning a significant lung nodule is a significant miss. Second, I have some advice for residents: Keep a single list of all meaningful errors you make. Unless you happen to be reading out with Dr Jha; in that case, consider having multiple lists.
The author has no conflicts of interest related to the material discussed in this article. Richard E. Heller III, MD, MBA: Radiology Partners, 2101 E El Segundo Blvd, Suite 401, El Segundo, CA 90245; e-mail: richard. [email protected].
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Journal of the American College of Radiology Volume - n Number - n - 2017