Jul 30, 2011

How doctors think by dr. Jerome Groopman is not really about how doctors think. It's about how people think, and how this affects our work as doctors. Groopman states he primarily wrote the book for patients, to explain how doctors come to their decisions: which may well be wrong and may have devastating consequences. Practicing medicine is time-pressured decision making in the face of many uncertainties, over and over again. You only need a distraction, a bad night's sleep, or a stressful situation to miss a bit of information that would have been vital for correct diagnosis.

How doctors think

Groopman proposes four simple questions to ask yourself to avoid making mistakes in diagnostic decision making:

  1. What else could it be?

    Deals with errors such as premature closure, framing effect, availability from recent experience, bias towards more common disease. It helps to keep an open mind, forces to think of alternatives that are maybe less common. As students, we were taught to think in terms of differential diagnosis, but this concept is often sacrificed in a busy medical practice.

  2. Is there anything that doesn't fit?

    Deals with diagnostic momentum: once a patient receives a diagnosis, it is very difficult to change it. Critically assessing signs and symptoms that don't fit with the given diagnosis, instead of brushing them aside, again helps to come to an alternative diagnosis.

  3. Is there maybe more than one problem?

    Deals with search satisfaction. In my profession, this is a common pitfall. We read our scans, and stop looking when we've found something, particularly if it fits the given diagnosis. Obsessively going through all images, assessing all organs and structures is the way I deal with this issue.

  4. Should I consult a colleague?

    Deals with our - oversized - ego! We're often stuck in our own ways of thinking, unable to get a fresh perspective. A colleague can help.

The problem with cognitive errors is that we're not really aware of them at the time. In my experience, they are the main cause of mistakes I made, mostly when I was exhausted after working too many hours... The trouble with exhaustion is that although you're aware of your attention is slipping, you're too tired to correct for it. And that's when you stop being critical about your own thinking. Maybe the four questions should be printed on the on call beepers as a constant reminder.

From the above you would think that Groopman's book is in fact written for doctors, and not for patients. Interestingly, however, Groopman also places some responsibility with the patients, advising them to ask their doctors these same four questions. I completely agree, but at the same time am quite relieved that I generally only work with scans, which don't ask such challenging questions!

Dec 1, 2010

Completely unrelated to RSNA, although it was pointed out to me here and it is related to Radiology, I found out today that our CHIP prediction rule - to predict intracranial complications after minor head injury - is included in the MediMath app for iPhone and iPad! It is only 3 years ago that the reviewers for our paper commented that the CHIP prediction rule may be too complicated for clinical practice, which is why we also included a simple list of risk factors for clinical use. This simplification leads to a slightly worse performance of the rule, so I'm really chuffed that the more complex rule can now also be used easily. If I hadn't found myself a justification for buying an iPhone, I definitely have found it now ;-).

Michigan Ave

Nov 30, 2010

As if yesterday's special lecture wasn't special enough.. today we've got President Bill Clinton! Most of today was therefore spent in anticipation, and in the long long queue several hours before doors opened. Well worth it: prime seats (well, relatively, for non-VIP standards anyway).

Bill Clinton

What can I say, it is incredible to hear this man speak, on health care both in our own rich countries, where we spend 10-20% of our GDP on health care, and in the developing countries, where cancer care is still virtually non-existent. What can we do? Make sure that we find ourselves in a position where we can have influence. Apparently, even in the United Nations this is not obvious, so each member every year promises that they're going to try to improve one thing... So tonight, I introduced this concept to my colleagues who I visit RSNA with every year. Each year, during RSNA, high up in the sky in the Signature Lounge overlooking Chicago, we will specify the one thing that we're going to improve in the coming year. A big promise to myself, my colleagues, my patients and to Bill!

Nov 29, 2010

Today's absolute highlight is Atul Gawande. I am a big fan of his books, which I think every doctor should read, reread and then read again. And today he's giving a talk at our own RSNA. What an honour.


Prior to his talk Sam Gambhir gave the Pendergrass new horizons lecture on strategies for early cancer detection. A truly impressive talk, on the ultra-high-tech developments for cancer detection in the earliest of stages, but it very much reminds me of the 7T MRI discussions: there's this niggling question in the back of my mind whether we can really justify all this expensive equipment and research while in large parts of the world children die of diarrhea...

The contrast with Gawande's subsequent talk therefore couldn't be bigger. The simplest technology possible, a checklist, reduces post-surgery mortality by 45-50%. It is really impossible to believe. All we can do is hope and pray that these simple measures really make their way into clinical practice as soon as possible so they can start taking their effect. We can have all the high-tech shiny toys we want, but if we don't stick to the basic principles such as hygiene, haemorrhage control, and patient follow-up, we are only making health care more expensive, but not better.

I was left deeply impressed and truly inspired, yet again, by this amazing person. Please, read his books and be a better doctor.

Nov 28, 2010

Hello Chicago!! RSNA number 8 for me and never failing to impress.. The sheer size of this meeting, incredible organisation, gathering of so much knowledge and technology every year leaves me with a slight sense of bewilderment, enhanced by the lack of sleep from jet lag and late night social events.


Excellent refresher course on advanced MR angiography: it is now possible to perform 3D time resolved (so, 4D in fact) whole brain angiography at 2 f/s with good separation of the arterial and venous phases and sub-millimeter resolution using HYPRFlow. The expectation is that time resolution of such techniques will go up to 20 f/s in the near future, unbelievable. Diagnostic DSA will really become a thing of the past.

Siemens introduced their 3T PET-MRI, yet another big shiny toy in the world of Radiology!

Aug 2, 2010

Our recently published cost-effectiveness study on the use of CT in the assessment of patients with minor head injury has been added as an abstract to the NHS Economic Evaluation Database.

This publicly available database, covering studies in all languages published from 1994 onwards, contains structured abstracts of full economic evaluations. As well as a structured abstract, a critical appraisal of our study was made: "the study was well conducted (...) The authors' conclusions appear to be robust". Hurray!

Jul 16, 2010

I have recently discovered Papers, a beautiful software package for Mac to organise my scientific papers: absolute heaven! I used to have lots of folders with downloaded pdf's, named by subject and numbered according to my Endnote libraries so I could keep track of them, but of course I could never find anything in the end.

I am now in the process of importing all of these scattered pdf's into one large Papers library. For an obsessively organised person like me, this process itself is already utter joy: I drag the pdf into Papers, click "match" and the programme then finds the metadata, places it in the library, and renames the pdf according to a standardised format. It all looks so neat! Oh, and it makes a really funky sound after a successful match :-)

So now they're all together, I can organise my papers further into (smart) collections, tag them, mark them read/unread, flag them, etc. And I can still use Endnote for my bibliographies, which, for the time being at least, is needed for the work in progress. Basically, you can export any selection of Papers to an Endnote XML file (select "Endnote 8 or higher"), and then import into an Endnote library (be sure to select "Endnote Generated XML"). After having set the temporary delimiters to curly brackets in the Preferences section, you can then use Papers (or Endnote) to copy the selected papers as (Shift Command E) an Endnote citation into your text editor.

Nov 12, 2009

Last week I organised the fMRI and DTI Hands-On Course on behalf of the European Society for Magnetic Resonance in Medicine and Biology (ESMRMB) in Rotterdam. It was fun, but, man, I really wasn't prepared for the immense amount of energy this would take.


Mind you, the course was a success, due to the efforts of the excellent speakers and practical assistants. I really do hope that the participants realised how amazing it is to be able to listen to both Stefan Sunaert and Derek Jones on the same course - some of the best speakers in their field - and have so many highly expert faculty members around for 3 days to guide them through the basics of fMRI and DTI acquisition and data analysis.

This year was the first year for ESMRMB to organise these so-called hands-on courses, while already having a long-standing successful MRI teaching programme in the form of the School of MRI. The hands-on courses are specifically aimed at radiographers/technicians, but it seems there is also a need for hands-on courses among radiologists, physicists and PhD students, who also attended the course in Rotterdam and were equally enthusiastic.


I do realise now why hands-on courses are so scarce and I have gained a huge respect for those organising such very practical courses (such as the FSL course). Not only because it's such an awful lot of work, but also because there are so incredibly many things that can go wrong, which are entirely beyond your control - not at all compatible with my personality type!

But, it was fun, and the social programme... priceless ;-)

Oct 23, 2009

I have recently entered the Female Career Development Programme, organised by my employer Erasmus MC. No doubt this programme has been inspired by the fact that only 7% of professors at Erasmus University are female; a percentage that is well below the national average (12%), which in turn is very low in comparison to the European average (19%). As the Netherlands aim for a national average of 25% by 2030, it seems time for drastic measures. The Female Career Development Programme, in my case.

I have to say, I was a bit sceptical about the whole thing. We've heard about the glass ceiling far too often already, and talked about it even more. Almost without exception, any meeting I've been to about female career development - or the lack thereof - very quickly descends from a reasonable discussion about facts and figures to a bitching session about our men never emptying the dishwasher and scattering dirty socks around the house. Extremely important topics, I agree, but much better discussed over cocktails with my girlfriends on a drunken night out.

So, after having been put forward by my boss, writing a long letter stating my fierce ambitions, and an excruciatingly slow selection procedure, I'm in. I was really dreading the glass ceiling discussion, yet again, and looked at my fellow female fiercely ambitious colleagues with suspicion, expecting a tirade about male nonchalance any moment.

But it was okay actually. We kicked off with a 2-day intensive programme during which we really got to know each other and talked about the many difficulties of combining clinical work with research, and, oh yes, a social life as well. But, no bitching, no complaining, no finger pointing, just practicing those difficult situations over and again to learn to deal with them.

The highlight was the final exercise: we wrote down our aims for the next meeting, and then passed them round to the others. So I ended up with a list of my aims, with lots of sweet and encouraging little notes, tips and comments written around them. Really, however ambitious we are, we still love those lovely little girlie things!

Apr 30, 2009

Today is Queen's Day in the Netherlands, the day when we celebrate the Queen's birthday on the date of our previous Queen's birthday. It is a happy day, with music festivals all over the country, flags everywhere and many people dressed in our national colour orange. To an outsider we must seem like an extremely monarchist and nationalist country, celebrating the Queen's birthday so exuberantly, but I don't think that's really it. The beautiful thing about Queen's Day is the fact that we can just be happy, together, without any particular reason. The Queen's birthday is just a good excuse. It is very much like when winning the World Cup, but without the football and crucially, without a losing team. There are no enemies on Queen's Day, no opposing groups or religious disagreements. In a time when worries about economic crisis, swine flu and terrorist attacks dominate our lives, this day of careless celebration seems all the more important.

And that's why today's events have been so shocking: a man drove his car at high speed through the celebrating crowds, presumably en route to attack the royal family who at that moment were passing through. Four people are dead, five severely injured and the nation is in mourning.

Like so many public events, Queen's Day has now also lost its careless innocence and will probably never be the same again.