In radiology, educators must balance 'the known' and 'the unknown'

Modern radiology educators have grown too reliant on “the known”—asking straightforward questions with only one correct answer—and should consider embracing “the unknown,” according to a recent editorial published by the Journal of the American College of Radiology.

Christian W. Cox, MD, of the Mayo Clinic in Rochester, Minn., and Richard B. Gunderman, MD, PhD, of Indiana University in Indianapolis, co-authored the article, emphasizing that focusing too much on the known has certain limitations radiology leaders should investigate.

“In many cases, the ‘right’ answer is but a limited truth, and a truly well-educated and highly competent physician knows more,” Cox and Gunderman wrote. “For example, a physician certified in cardiac life support may understand the resuscitation algorithm and employ it perfectly in practice, yet fail to recognize the underlying pathology that led to cardiopulmonary arrest and thus overlook an opportunity to save a life.”

And, the authors added, some questions just do not have clear answers.

“All the questions to which we think we have the answers today were once of this unknown nature—not only weren’t the answers known, but the questions themselves were once novel,” Cox and Gunderman wrote.

The authors went on to express their concern that radiologists could potentially form bad habits by being brought up through a learning experience where all questions have a right answer and then many wrong answers. It could blunt a radiologist’s curiosity, for instance, or take away their ability to ask complex question.

And how can educators avoid such side effects? By being unafraid to explore the mysterious from time to time.

“Simply put, we need to teach the unknown—the fact that all radiologists, even the leaders in the field, encounter questions every day to which they do not know the answer,” Cox and Gunderman wrote. “Consider, for example, the often unquestioning use of the term ‘idiopathic.’ To recognize and address only questions to which the correct answer is known would be to stop expanding the envelope of radiological knowledge.”

One way to teach the unknown, the authors said, is to present medical students and trainees with more cases to which the correct answer has not been determined. Another way is to ask the students and trainees to bring forward their own questions about intriguing cases.

“Only by encountering the limits of our own knowledge can we identify questions worth exploring further,” Cox and Gunderman wrote. “By ‘explore,’ we mean not looking them up in a book, but trying to figure out an approach to understand them better and begin to get some answers.”

The authors presented one noteworthy side effect of focusing more on the unknown: It helps do away with some of the distance people often see between “those who know” and “those who don’t.” It put everyone on the same level in a way, asking the educator and the learner to inhabit similar roles. And while this may be difficult for some learners who have grown up surrounded by the known, it is a valuable experience that teaches them that there is nothing wrong with admitting one does not always have immediate answers.

“Those who cannot admit the limits of their own knowledge fall victim to pretending that they know something they really don’t, simply to save face,” Cox and Gunderman wrote. “The intellectual integrity of the field hinges in part on the resistance of radiologists to sustaining a façade of perfection, even and perhaps especially when it is most tempting to do so.”