• Dr Sally Ayesa

Dropping a case: seeing the plus side

While you are preparing for your radiology viva exams (and indeed for your time as radiologist), you cannot avoid the hot seat. You will need to spend a lot of time over the course of your learning reading and presenting cases in front of your consultants and peers, which is inevitably followed by feedback. Sometimes, you will nail it. A lot of the time, you won't, especially when you are starting out or accelerating your exam preparation.

This is all part of the medical imaging learning process, however when it happens to you it is humbling. On days when you are feeling confident, motivated and eager to learn, you take the feedback with open arms. On days when you are feeling particularly vulnerable, it can be devastating. For this reason, it can be helpful to consider all the potential benefits to dropping a case so you can have less days where the dropped case stings and more where the stumble motivates you to become better.

You remember more from your mistakes than your successes

In my very first case presentation (in front of the whole radiology department on my fourth day on the job), I was shown a foot x-ray with a non-united apophysis at the base of the 5th metatarsal. I called it a Jones fracture. I was wrong, and I will never forget the case or the diagnosis. Do I have any recollection of the first case that I correctly presented? Not at all.

During the course of my learning, my mistakes burned into my brain much stronger than my successes - and I am not alone. It has long been accepted in psychology that we are more likely to remember negative or traumatic experiences than the positive ones. Scientifically, the adrenaline released during stressful situations known to impact the amygdala (and other components of the brain implicated in memory), resulting in up-regulated memory formation during these stressful times.

Sitting in the hot seat presenting cases might be all the stress you need. But if you want to take it up a notch, try presenting in front of bigger rooms of colleagues, larger tutorial groups and formal practice vivas to get your adrenaline flowing. Not only are these great practice runs for the stress you will be under on the day of the exam, but if you drop a high yield case in a high stakes context you will have a greater chance of remembering it on the day of the actual exam.

Use mistakes to unearth weaknesses in your knowledge

Some cases are specific to a particular diagnosis (the 'Aunt Minnies') and a quick visit to a textbook or Radiopaedia.org will get you up to speed. For others, it can unearth a whole topic area which you can work on. This would include things topics like suprasellar masses, arthritides or lung nodules.

In my preparation, I was in constant cycles of this. A one point, I was struggling when faced with masses in the pineal region - so I spent a bit of time working through this group of differentials. When I was having trouble with interstitial lung disease, I read through chapters of Elicker & Webb to review nodules, septal thickening and patterns of fibrosis. When you do this, try to think about the patterns you see and how they would allow you to formulate a diagnosis. This helps to develop your problems solving skills as well as your knowledge, which are equally important.

Consider where you went wrong

Lack of knowledge is not the only reason that candidates struggle with cases. I find there are many reasons, including lack of experience with the diagnosis or group of diagnoses, technique issues and confidence issues.

Lack of experience with the case, despite good textbook knowledge, can lead to difficulties in interpretation. A perfect, static image in a textbook is not an accurate reflection of real-life practice - and the only way you can develop this skill is by presenting the cases over the course of your preparation.

In some cases, your knowledge base may be sound and you may be familiar with the case, but the technique might not be coming together. Was it because the presentation lacked structure? Were you misguided by incidental findings and tangents? Did you correctly describe all the findings but have trouble pulling it together? Was your management lacking? Remember that technique needs to be developed as much as knowledge when you are growing as a radiologist and preparing for exams. It helps to think about these questions as if you were writing a report. A good report is succinct, has a logical flow and structure, with a sensible diagnosis offered based on the findings and management provided if needed - just like a sound viva presentation!

Sometimes you are almost there... a few tweaks and you are on the road to success.

Others can learn along with you

If you miss a case in front of a group of colleagues, chances are that at least one of them wouldn't have nailed it either. Try to remember that group tutorials aren't for grilling one person, but more for sharing learning experiences and growing as a group. That interesting case of the soft tissue sarcoma? It isn't just for the person in the chair, but all of you together. Consider also that your tutor probably gets a kick of showing off his or her favourite cases, and relishes sharing their own learning with the rest of you.

Your tutor might not have nailed it either

I am constantly telling my candidates the stories of where may cases came from, and why I took the time to print them and add them to my bag of films.

"I missed this anterior process of the calcaneus fracture when I was on an overtime shift in first year. It can be a tricky diagnosis to make."

"I make sure I show this case of a central lung cancer because I incorrectly under-called it in an multidisciplinary team meeting, and I don't want you to make the same mistake. Here are some tips I have learned in approaching this case."

While I can't speak for other tutors, part of my teaching style is helping others learn from my mistakes. I figure if I didn't get it, there is probably a learning point in it for others. Also, keep in mind that while the person sitting in the chair seems like they are all over the pathology, they have presented the same case over and over, and had the opportunity to learn from the candidates before you.

Putting it in perspective

As you begin to train as a radiologist, or start your exam preparation in earnest, you are not going to be across everything - and that is alright. Even as you work through different knowledge levels, there will be some times of transition in your problem solving which will require adjustment. Radiology exams take months (if not years) to prepare for, and you ideally want to peak just before you sit them. Naturally, the amount of cases you drop will become less and less as your knowledge and understanding builds, and you need to allow your self time for this process to happen.

You will be going through a time of great personal and professional growth. While you need to embrace your short comings, try to remember to celebrate your successes in equal measure. You have already achieved more that you realise, and are well on your way to success.

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