Okay, so I want to start today by throwing a
term at you. And I guarantee, unless you're,
I don't know, a very specific type of doctor
or maybe a lawyer who's deep in industrial lawsuits,
you have never heard this before. And honestly,
it sounds, it sounds underwhelming. Oh, yeah.
What's the term? Bereader. Ah, yes, it does sound
a bit. Second rate, doesn't it? Right. I mean,
if I told you I was a B reader, you'd assume
I was the understudy. The backup plan, the person
who reads the script when the A reader is out
sick. Or maybe someone who only reads, like,
B -list celebrity autobiographies. Exactly. It
just implies lesser than. But what if I told
you that being a B reader is actually one of
the most elite, exclusive, and high -pressure
designations in the entire American medical system?
That is a much, much more accurate way to put
it. It's a tiny club of people with a very, very
specific skill set. And what if I said these
people hold a power that is, frankly, kind of
terrifying? Imagine a job where you're sitting
in a dark room staring at this blurry black and
white image of a lung. And your opinion, your,
you know, subjective take on a shadow, can decide
the fate of massive lawsuits, millions of dollars,
and the medical truth for thousands of workers.
It's the ultimate high -stakes game. And the
B definitely does not stand for backup. So today
on The Deep Dive, we are unpacking the very strange
world of the B -reader. We're going to look at
this intersection of, um... medicine, human error,
and the law. We've got NIOSH protocols, some
pretty dense medical journals, and a few legal
studies that I think are really going to make
your jaw drop. And it's a perfect topic because
it really challenges something we all just assume,
you know, that medicine is subjective. We think
an x -ray is a picture of the truth. But as we're
about to find out, an x -ray is just a shadow.
And shadows can change depending on who's looking.
Okay, so let's start at ground zero. What technically
is a bee reader? Okay, so a B -reader is a physician.
They're usually already a specialist, like a
radiologist or a pulmonologist, but they've gone
a step further and gotten certified by NIOH.
That's the National Institute for Occupational
Safety and Health. And their whole job, their
specific certification, is to classify chest
x -rays for signs of pneumoconiosis. Pneumoconiosis.
That's the big umbrella term for like dust diseases.
That's it. Yeah. It comes from the Greek. Pneumo
for lung, conus for dust. So you're talking about
things like asbestosis, silicosis, and the one
that really kicked this whole thing off. Coal
workers, pneumoconiosis. black lung. So these
are the doctors who look at a long x -ray and
say, yep, there's dust damage here, or nope,
these lungs are clear. Well, see, that's where
you have to be really careful with the wording.
You said diagnose, which implies you're treating
a patient. A B reader isn't necessarily diagnosing
someone in that clinical sense. They are classifying
an image. That feels like a subtle distinction.
What's the real difference there? A clinical
diagnosis is holistic. A doctor looks at you,
listens to your breathing, asks about your history.
A B reader is doing something much colder. It's
epidemiological classification. They are looking
at an image and mapping it against a really rigid
international standard to generate a data point.
So they're turning a picture into a spreadsheet
entry. Precisely. And to do that, they use a
system called the ILO classification. That's
from the International Labor Office. And this
is where the science part gets really, really
intense. I was looking at the notes on this ILO
system and it is just. It's wildly complex. It's
not just, is there dust? Yes or no? Not at all.
It's a whole language. When dust gets in the
lungs, the tissue reacts by forming these little
scars, fibrosis. On an x -ray, they look like
small white spots or opacities. The ILO system
makes the doctor describe those spots with incredible
precision. First, the shape and size. And they
use letters for this, right? Like P, Q, R, R.
They do. So if the spots are round, you have
to measure them. Are they type P? That's up to
one and a half millimeters. Are they type Q?
That's one and a half to three millimeters. Yeah.
Or are they type R3 to 10? So you're distinguishing
between a dot the size of a pinhead and one the
size of a lentil on a blurry film. Exactly. And
that's just for the round ones. If the scars
are irregular like little lines or squiggles,
you have to classify them as type S, T, or U
based on their width. And then you judge how
many there are. Sort of. You judge the profusion,
the density, how crowded are these spots. And
this is the part that just blows my mind. They
don't just use a simple 1, 2, 3 scale. They use
a 12 -point scale that actually incorporates
uncertainty. I saw this in the notes. One slash
zero or one slash two. Explain that because it
seems so weird. It's not a fraction. It's like
a mental toggle. So let's say I look at an x
-ray. I think it's a category one definite, but
light scarring. But I hesitated for a second.
I briefly thought maybe this is a category zero,
which is normal. So I coded as 10. So the code
literally says I landed on one, but I thought
about zero. That's it. Or 21 means I decided
it's a two, but I considered calling it a one.
The system is built to capture the doctor's own
internal debate. It acknowledges that the line
between healthy and sick is, you know, fuzzy.
That is incredibly nuanced. It's like they're
trying to build a mathematical model for human
hesitation. They are. And that is why you need
a special certification. You can't just grab
any doctor and ask them to distinguish a type
Q opacity from a type R while deciding between
11 and a 12. Okay, so why did this whole system
get created? Why couldn't regular radiologists
just handle it? Because of the absolute chaos
of the 1970s, you have to go back to the origin
story here. 1974. The era of bell bottoms, the
energy crisis. And a massive focus on coal miners.
Right. The federal government had this huge surveillance
program for coal miners. They were taking thousands
of chest X -rays to track black lung. But when
the data came back, they found a huge problem.
Which was? Reader variability. Which is just
a polite scientific way of saying that doctors
couldn't agree on anything. It was a mess. I
mean, you'd send a miner's x -ray to a doctor
in Kentucky, and he'd say, this man has stage
2 fibrosis. Get him out of the mine. You send
the exact same film to a doctor in West Virginia,
and he says, totally clear, send him back to
work. That is a nightmare. For the miner, I mean.
Yeah. Your whole life, your health, your compensation,
your job, it all depends on which doctor happens
to pick up your file. It was scientifically unacceptable.
And legally, it was a disaster. It just proved
that truth in these images was totally subjective.
So NIOSH stepped in. They said, we need to calibrate
the human eye. And they launched the B -Reader
program. And just to close the loop on the name,
I saw a note that the B probably stands for the
Black Lung Program. That's the prevailing theory,
yeah. The Black Lung Connection. But honestly,
given how hard the exam is, the B might as well
stand for brutal. Let's talk about that exam.
Because this isn't some weekend seminar with
free bagels. Oh, not at all. Becoming a bee reader
is famously difficult. Just to give you a sense
of the scale, as of October 2017, how many certified
bee readers do you think there were in the entire
U .S.? I don't know. There are thousands of radiologists.
Maybe a thousand. 181. 181. That's it. For the
whole country? That's it. Plus about 58 international
ones. It is a microscopic club. Why so few? Does
nobody want to do it? Oh, people want to do it.
It can be very lucrative. But the exam is a massive
filter. It takes place at one specific lab alert,
the Appalachian Laboratory for Occupational Safety
and Health in Morgantown, West Virginia. Even
the location sounds intense. Right in the heart
of coal country. It is. And the test involves
a timed classification of 125 different radiographs.
You have to sit there under the clock and correctly
classify 125 x -rays using that super strict
ILO standard. You have to get the P's and Q's
right. You have to nail the perfusion. And you're
graded against a master key, right? A consensus
from a panel of experts. Yes. And if you deviate
too much, you fail. The pass rates are historically
low. But here is the real kicker. It's not like
a degree where once you have it, you have it
for life. Every four years. If you don't pass
the recertification exam, you lose your status.
You're out of the club. That's incredible pressure.
It's like having to retake your final exams every
four years for your entire career. It's to make
sure their skills don't drift. Because remember,
the original point was for research and compensation
data. They needed the human eye to act like a
machine. So we have this elite, super trained,
constantly tested group of 181 experts. Theoretically,
this should solve the variability problem. We
should have perfect objectivity. Theoretically.
But this is where the story shifts from, you
know, a medical science story to more of a legal
thriller because the context started to change.
We move beyond just monitoring coal miners. Right.
Bee readers became critical for all the dust
diseases, asbestos, silica. And suddenly we weren't
just talking about government surveillance. We
were talking about toxic torts, massive lawsuits.
And where there's litigation, there's money.
Huge money. Billions. And where there is money,
there is pressure. So let's unpack variability
again. We talked about random variation, just
doctors disagreeing. But the sources highlight
a different kind. Systematic variation. Which
is a polite way of saying bias. Well, is it corruption?
Well, let's stick with the science of bias for
a second. It can be cognitive. It happens when
a reader has outside information that primes
their brain. So if I hand you an x -ray and I
say... This is Mr. Smith. He's 65, and he worked
in an asbestos factory for 30 years. What is
your brain going to do? My brain is going to
go hunting. I'm going to expect to see damage.
I'll squint at every shadow until it looks like
a problem. Exactly. You lower your threshold
for calling something positive. It might not
even be conscious. You're just primed to see
the pattern. But then you add the money. If I'm
a lawyer for Mr. Smith, I need a positive read
to win my case. If you, the doctor, give me a
negative read, well, I don't pay you for your
testimony. I just go find another doctor. And
that creates a marketplace for positive readings.
And this leads us to the most explosive piece
of evidence we found, the Gitlin study. I read
this three times. I had to make sure I wasn't
misinterpreting the numbers. This study basically
took a flamethrower to the whole idea of B -reader
objectivity. So walk us through the setup. Okay.
So they had a set of 492 chest x -rays. Group
A was B readers who were retained by lawyers
in asbestos litigation. These were the hired
guns for the plaintiffs. Group B was an independent
panel of B readers who were blinded. So they
didn't know who the patients were, no history,
and they weren't being paid by a lawyer to find
a specific result. So Group A, the plaintiff's
experts, versus Group B, the neutral scientists,
same films. What happened? The B readers hired
by the lawyers found abnormalities, signs of
disease in 95 .9 % of the cases. 96%. Okay, so
basically almost everybody's sick. Almost everyone.
Now, the independent blinded panel looking at
the exact same images, they found abnormalities
in only 4 .5 % of the cases. Wait, stop. Let
that sink in. 96 % versus 4 .5%. That's the gap.
That is not a gap. That's a canyon. I mean, if
it was 60 percent, it's 50 percent. I'd say,
OK, subjective. But 96 to 4. That means one group
is seeing a plague and the other group is seeing
a room full of healthy lungs. It highlights the
massive, massive impact of context and financial
incentive. The study suggests that when you are
hired to find something, you find it. And remember,
these aren't just random doctors. These are all
NISH certified bee readers, the elite 181. This
is just, I mean, the implications are huge. If
a lawyer can hire a B reader who will say positive
96 % of the time, that's almost a guaranteed
ticket to a settlement, isn't it? The certification
itself was being weaponized. That's exactly the
argument that started to be made, that the B
reader stamp of approval had become a commodity.
Lawyers weren't hiring the most accurate doctors.
They were hiring the most positive doctors. But
just to play devil's advocate for a second, is
it possible the independent panel was wrong?
Maybe they were being too conservative. It's
possible. Radiology is subjective. But a 90 point
spread. That suggests something systemic is going
on. It suggests that objectivity dissolves when
you know which side you're playing for. So surely
NIOSH didn't just let this go. I mean, their
entire mission is accuracy. If their gold standard
certification is being used to game the legal
system, that's a really bad look. It was a crisis
of credibility. Absolutely. And this brings us
to the cleanup phase. NIOISH responded by establishing
a formal code of ethics for all B readers. We
have the code here. It's 10 points. And honestly,
reading through them, some of these feel like
things you shouldn't have to write down for a
doctor. Usually if a rule exists, it's because
someone somewhere did the opposite. Right. OK,
look at rule eight. B readers shall not accept
compensation that is... contingent upon the findings
of their chest radiograph classifications. That's
the bounty hunter rule. It tackles that problem
head on. You can't have a fee that says, I get
$500 for a negative reeb or $5 ,000 if I find
disease. That is explicitly forbidden. You get
paid for your time, not for the result. That
seems like ethics 101. It is. But you can imagine
how creative the incentives could get. This shuts
that down. Then there's rule three. Bee readers
shall not make clinical diagnoses. Based on chest
radiograph classification alone. And this circles
back to what we said at the very beginning. A
B reading is a classification. It's a data point.
It is not a diagnosis. A doctor can't use this
form to tell a patient, you have asbestosis.
You need more evidence than that. But then look
at rule four. This one feels like the moral safety
net. It says if a B reader sees something clinically
important, they have to make sure the individual
gets notified. Right. Because imagine you're
a B -reader hired by a company. You're blinded.
You get an x -ray and you see a massive tumor.
But your only job is to look for dust. Technically,
you could just check the no dust box and move
on. And the patient could die a year later because
nobody told them. Exactly. Rule 4 says you have
a duty to the human being, not just to the form.
You have to make sure someone alerts the patient.
You can't just hide behind the process. And the
sources also mention a big push for blinding.
as a recommended practice. It's the ultimate
fix. The Gitlin study proved it works. If you
want the truth, you have to hide the context.
If the reader doesn't know who the patient is,
who the lawyer is, or the job history, that bias
just evaporates. The 96 % drops down to 4%. It's
so ironic, isn't it? We usually think that to
make a good decision, you need more information.
But here, to get to the truth, the doctor actually
needs less information. That is the whole paradox
of the B -reader. Context creates a narrative
and narrative creates bias. To get to the raw
data, the truth of the photons on the film, you
have to strip the story away. So where does this
leave us today? Is the program still running?
It is. It's still the gold standard for tracking
occupational lung disease. The exam in Morgantown
is still brutal and the certification is still
incredibly rare. But are they still fighting
this variability battle? I think variability
will always be a factor as long as humans are
doing the reading. The whole B -Reader program
is an attempt to standardize human perception.
It's an attempt to turn a subjective opinion,
that shadow looks weird, into objective data.
And maybe that's the real takeaway here. We think
of medical tests as binary, positive or negative.
You have it or you don't. But an x -ray is just
a shadow on a plate. It requires interpretation,
and interpretation requires a human brain. And
brains are messy, pattern -seeking, bias -prone
things. It really makes you think, we spent this
whole time on chest x -rays, but if these trained
experts, the elite 181, can disagree 96 % versus
4 % of the time, depending on who's signing the
check, where else in medicine is objectivity
just an illusion? What's happening with MRI interpretations
for back surgery? or pathology slides for cancer?
That's a really uncomfortable question, isn't
it? The bee reader controversy just made it visible
because we had the data from that one study.
It makes you wonder what's happening in all the
areas where we haven't done the study yet. On
that slightly terrifying note, I think we'll
wrap up this deep dive. Always a pleasure to
undermine your faith in absolute truth. Next
time you see a medical report, remember the bee
reader. Remember the P's and Q's. And maybe think
about getting a blinded second opinion. We will
catch you on the next one.