Even well intentioned, honest people experience unconscious bias. Cognitive bias occurs when the brain uses shortcuts (sometimes called heuristics) to reach a conclusion quickly, without using a formal logical process. Heuristics are usually beneficial, allowing us

to avoid dangerous situations without the need to consciously evaluate our surroundings on a constant basis. However, in a legal context where opinions need to be fully evaluated, these unconscious biases can lead to unpredictable decisions.

Framing Bias

America's most famous practitioner of framing bias must be Tom Sawyer. As a clever kid, forced to whitewash the fence on a beautiful summer day, he convinced his friends not only to do it for him, but also to pay him for the privilege. How he presented his situation affected how the passersby evaluated it. In the same way, any radiologist who is given an exam by an attorney knows from the situational context that there is an extremely high likelihood that the study will be abnormal. The heuristic decision that it is abnormal leads to an unusually focused search

for the reason that the lawyer has given the exam to the reviewing radiologist for assessment. Cleareview minimizes this bias by inserting the exam at issue into a set of exams, all blinded, for presentation to the radiologist reviewer. This more realistic environment reduces the framing bias, resulting in a more neutral appraisal of each exam. The reader will not know how many problematic exams are in the stack, forestalling the expert reviewer's tendency to find the most problematic study and focus on it.

Hindsight Bias

"I knew it all along" "Hindsight is 20/20" "The Monday Morning Quarterback" The variety of common phrases we have for hindsight bias reflects our widespread experience with this phenomenon. Once an effect has been seen, the cause is obvious. Radiologists make countless heuristic decisions based on their learning and experience. Not all decisions turn out favorably, and when the bad outcome is analyzed, we naturally review all contributing decisions. A decision, especially a heuristic one that may be perfectly reasonable at the time it is made, looks very different when subsequent events turn out badly.

Outcome bias, very closely related to hindsight bias, is the tendency to judge decisions by their eventual outcomes, rather than in the light of what was known at the time. Cleareview addresses hindsight bias by blinding the radiologist to the outcomes of the cases being evaluated. The worklist contains the exam at issue as well as historical exams and their reports, so the reviewer has practically the same available information that the original radiologist had when the exam was initially read.

The Learning Effect

Most parents are familiar with Where's Waldo™, a series of books in which Waldo, a bespectacled boy in a red and white striped shirt, is hidden in a very busy picture. Children can spend a long time finding Waldo, but once they do, the books lose interest, because finding him the second time is so easy. Radiologists are professional searchers. Once they see something, it is impossible for them to 'unsee' it. The expert reviewer who sees a nodule, or glances at the report discussing follow-up scanning cannot ignore the information, even should he wish to. Cleareview addresses the learning effect as well.

Because the reviewer does not know which is the exam at issue, the original finding that has resulted in the lawsuit is not identified, and cannot be imprinted on the radiologists’ retina. In addition, our mode of presentation provides the reviewer with the same patient history the original reader put in the report, without the body of the report, so the reviewer has the opportunity to arrive at an independent conclusion without being biased by an unavoidable glance at the full report.

Using Cleareview

Our de-identified PACS is an image archive containing tens of thousands of radiologic images of every type. When you send a patient’s imaging studies to Cleareview, we de-identify them and insert them into the database. We then create an image set customized to the particular circumstances surrounding the case at issue, and the reviewer to whom the set of exams will be given. We will then contact the expert reviewer of your choice, and provide him or her with a login and password to access our PACS. The reviewer is presented with a list of exams, and grades each one using Cleareview’s proprietary scale. We then compare the reviewer’s grades against the reference database of scores, all made by board-certified radiologists, to determine how consistent the reviewer is with a larger pool of radiologists. Our report to you includes the grade your reviewer gave the case you provided Cleareview, along with an evaluation of how the reviewer’s scores of

the other exams compare to larger pool of radiologists. Our entire process is on-line and HIPAA-compliant. The PACS is zero-footprint, and runs in an Internet browser, so there is absolutely no information stored on the user’s computer. All exams are de-identified consistent with the highest standards currently available. The scores are entered into Cleareview’s database immediately, so there is no chance of data loss or transit delay. Our reports are timely, clear and accurate. Most importantly, Cleareview values integrity. We are as transparent as possible, and do not favor plaintiffs over defense, or defense over plaintiffs. Our mission is to clarify imaging matters so that less time and money is spent on dueling experts, and radiology disputes are resolved as quickly and fairly as possible.

Annotated Bibliography