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ORIGINAL ARTICLE
How to cite this article
INTERPRETING COMPLEXITY: HOW SENIOR CLINICAL FELLOWS APPROACH
CHALLENGING CARDIOTHORACIC IMAGING CASES - A QUALITATIVE STUDY
Khalid Shakeel Babar
1
, Junaid Sarfraz Khan
2
Babar KS, Khan JS. Interpreting
Complexity: How Senior Clinical
Fellows Approach Challenging
Cardiothoracic Imaging Cases - A
Qualitative Study J Gandhara Med .
Dent Sci. 2026:13(4): 41-46.
Date Submission: 03-05-2026
Date Revised: 06-09-2026
Date Acceptance: 10-09-2026
2
Course Co-ordinator, Health Services
Academy, Pakistan
Correspondence
1
Khalid Shakeel Babar, DHPE
Scholar, Health Services Academy,
Pakistan
:
:
+92-334-7231873
khalidshakeelbabar@gmail.com
ABSTRACT
OBJECTIVES
To explore how senior clinical fellows in cardiothoracic radiology approach
complex imaging cases in routine clinical practice, with secondary objectives
of understanding how they manage diagnostic uncertainty, the factors
inuencing their decision-making, and the development of condence and
independence during fellowship.
METHODOLOGY
A qualitative descriptive study was conducted involving seven senior clinical
fellows in cardiothoracic radiology at Liverpool Heart and Chest Hospital,
Liverpool, UK, between January 2026 and March 2026. Participants were
selected using purposive sampling based on relevant clinical experience. Data
were collected through face-to-face interviews using a structured
questionnaire containing open-ended and Likert-scale questions. Qualitative
interview data were analysed using Braun and Clarke’s six-phase thematic
analysis framework.
RESULTS
Five major themes emerged, including supportive environment in decision-
making, importance of clinical details, diagnostic uncertainty, decision-
making under stress, and experiential learning. Fellows reported that
consultant supervision, support and multidisciplinary discussions were
essential for managing uncertainty. Limited clinical information and
ambiguous imaging ndings increased diagnostic diculty. Clinical demands,
particularly in unstable patients, inuenced decision-making. Furthermore,
experience and literature review improved condence over time.
CONCLUSION
Decision-making in complex cardiothoracic imaging involves managing
uncertainty through senior Consultant support, mentorship, adequate clinical
information, and experience, which together improve condence in
interpretation and patient care.
KEYWORDS: Cardiothoracic Imaging, Clinical Decision-Making,
Diagnostic Uncertainty, Radiology Training, Qualitative Research, Medical
Education
INTRODUCTION
Cardiothoracic imaging at a dedicated tertiary care
cardiothoracic centre usually involves complex cases for
specialist opinion. The ndings may be subtle or too
complex for a general radiologist. Accurate
interpretation of these complex or subtle imaging
findings is of utmost importance, as it may alter the
management and outcomes of the patient. Discrepancies
in these special studies are expected to be higher than
normal. The usual approximate discrepancy rate of
radiological reports is 35% of studies reported.¹ There
is rapid change in teaching methods, and importance is
given to competency-based training and learning in
medical education. The newer teaching methods and
approaches, including ipped classroom, are being
employed in daily practice. This has led to changes in the
assessment of trainees and fellows. There is use of higher
cognitive-based assessment models and decision-
making tools, which include entrustable professional
activities. The newer models are replacing the traditional
methods of teaching and assessment.
,
It is evident that
traditional teaching and learning models do not fully help
students understand how clinical decisions are made in
real-world scenarios. Hence, clinicians with good
reasoning skills are developed through better knowledge
structures through repeated and variable real-world
clinical exposure using newer teaching methods.⁴
Clinical decision-making in real life is inuenced not
only by basic medical knowledge and technical skills but
also by factors such as uncertainty, time pressure,
workload and access to clinical support systems.⁵
,
⁶ These
themes and challenges are especially relevant in
cardiothoracic imaging, where the reporting radiologists
encounter multiple possible diagnoses and incomplete
clinical and surgical information is common. Senior
http://doi.org/10.37762/jgmds.13-4.927
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clinical fellows are at an important stage of training and
learning. They are expected to make some degree of
independent decisions during their training while still
counting on guidance from senior colleagues. The level
of independent decision-making depends upon the stage
of training and experience. Understanding how they
approach and diagnose complex cardiothoracic cases can
provide useful information for training, supervision,
clinical practice and help improve radiology training
programs. Therefore, the primary objective of this study
was to explore how senior clinical fellows in
cardiothoracic radiology approach the interpretation of
complex imaging cases in routine clinical practice. The
secondary objectives were to understand how fellows
recognise and manage diagnostic uncertainty, to explore
the factors that inuence their decision-making when
interpreting complex imaging cases, and to understand
how they develop condence and independence during
their fellowship.
METHODOLOGY
A qualitative descriptive study was conducted at
Liverpool Heart and Chest Hospital, UK, between
January 2026 and March 2026, involving seven senior
clinical fellows in cardiothoracic radiology. A
qualitative descriptive design was selected because the
study aimed to explore and describe fellows’ experiences
and approaches to interpreting complex cardiothoracic
radiology cases. The participants included current and
former fellows who had undertaken a structured senior
clinical fellowship in cardiothoracic imaging. The
Ethical Review Board, Health Services Academy,
Islamabad, Pakistan, approved the study (reference: RO-
423/2026/HSA/DHPE-V; approval date: 2 January
2026). Written informed consent was obtained from all
participants before participation in the study.
Participants were selected using purposive sampling to
ensure relevant clinical experience. The sample size was
guided by thematic saturation. Saturation was assessed
by reviewing the interview data as data collection
progressed and was considered to have been reached
when later interviews produced similar repetitive themes
without identifying any new themes. Recruitment was
therefore concluded after seven participants. Data were
collected through face-to-face interviews using a
structured questionnaire that included both open-ended
and Likert-scale questions. The structured questionnaire
ensured consistency across interviews and covered the
study objectives. It included open-ended questions that
allowed participants to describe their experiences and
perspectives in their own words. Qualitative interview
data were analysed using Braun and Clarke’s six-phase
thematic analysis framework. Following transcription
and anonymisation, the lead researcher repeatedly read
the transcripts to become familiar with the data and
generated the initial codes. Codes were compared across
participants and grouped according to recurring patterns
in the data. Related codes were then organised into
candidate themes. A second researcher reviewed the
initial codes and candidate themes to provide an
additional perspective on the interpretation of the data.
Any dierences in interpretation were discussed
between the researchers and resolved through consensus.
The candidate themes were subsequently reviewed
against the original interview data and rened. The nal
themes were dened and named to ensure that they
accurately represented participants’ accounts and
addressed the study objectives. This methodology
examines how radiologists make decisions in complex
cases by interviewing fellows and analysing their
answers to nd common patterns.
RESULTS
Seven senior clinical fellows participated in the study.
Their demographic and professional characteristics are
summarised in Table 1.
Table 1: Demographic and Professional Characteristics of
Participants (n = 7)
Characteristic Category n (%age)
Gender
Female 04 (57.1%)
Male 03 (42.9%)
Duration as Senior
Clinical Fellow
36 months 02 (28.6%)
912 months 04 (57.1%)
>1 year 01 (14.3%)
Participants generally rated cases as moderately to
highly complex, with moderate to high condence in
identifying complexity. However, uncertainty was
common, with most fellows reporting occasional to
frequent uncertainty, often of moderate intensity as
shown in Chart 1.
Almost never,
0, 0%
Occasionally,
1, 14%
Sometimes,
4, 57%
Often,
2, 29%
Chart 1. How often do Senior Clinical
Fellows feel uncertain when reporting
complex cardiothoracic cases?
Almost never Occasionally Sometimes
Often Almost always
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Table 2: Themes and Subthemes Inuencing Clinical Decision-
Making
Theme Subthemes Representative
Quotes / Findings
Clinical
Support
Systems
Consultant supervision “Having an available
consultant nearby for
advice if I am
uncertain.”
Multidisciplinary
discussion
“Discussion with
clinicians helps
pinpoint diagnosis.”
Peer and team input Fellows reported
better decisions with
shared opinions
(“two heads are better
than one”).
Clinical
Information
Availability of clinical
history
“Knowing the exact
clinical history and
intraoperative notes.”
Operative details Accurate operative
information
improved diagnostic
condence.
Lack of information Missing data
increased uncertainty
and required further
imaging or
discussion.
Diagnostic
Uncertainty
Overlapping imaging
ndings
Difculty
distinguishing
haemorrhage vs
surgical material
Complex
vascular/postoperative
cases
Endoleak vs
penetrating ulcer
confusion
Inadequate imaging Poor-quality imaging
increased
uncertainty.
Decision-
Making
Under
Pressure
Time constraints Rapid decisions
required despite
incomplete data
Clinical urgency Managing unstable
patients
Stress and cognitive
load
Balancing speed with
diagnostic accuracy
Learning
Through
Experience
Case exposure Recognition
improves with
repeated cases
Consultant feedback Helps rene
decision-making
Self-directed learning Literature review and
case-based learning
Increasing
independence
Transition from
reliance to
condence over time
Fellows reported a strong sense of responsibility and
moderate condence in managing uncertainty. Most
sought consultant support regularly, particularly for
complex cases. Time pressure had a moderate impact on
decision-making, and stress was reported occasionally to
often. All participants noted increased condence over
time. Qualitative responses highlighted the importance
of consultant support, clinical information,
multidisciplinary discussion, and experience in
managing complex cases, as given in Table 1.
The ndings show that managing complex
cardiothoracic imaging cases is inuenced by multiple
interacting factors, including clinical support systems,
clinical context, uncertainty, and experience. Most
participants reported increased condence over time,
with the majority feeling more condent in managing
complex cases during their fellowship.
Theme 1: Clinical Support Systems in Decision-
Making
Fellows said they make better decisions when they have
support from consultants and the wider team. When
cases get tricky, having a senior radiologist involved
makes a big dierence. It gives them condence and
helps them avoid going down the wrong path. As many
would say, “two heads are better than one.” They also
valued team discussions, like MDT meetings. Hearing
dierent viewpoints helps build a clearer picture and
ensures nothing important is missed. It is a way of
keeping each other in check and learning along the way.
Overall, good support means fellows are less likely to
second-guess themselves and more likely to reach the
right decision. In simple terms, fellows make safer and
more condent decisions when they can talk things
through with experienced colleagues instead of going it
alone. “Having an available consultant nearby for advice
if I am uncertain.” “Discussion with clinicians helps
pinpoint diagnosis.”
Theme 2: Importance of Clinical Information
Fellows said that detailed clinical information and
concise clinical questions are essential for interpreting
imaging correctly. When they had clear details, such as
the patient’s history or operative notes, it made decision-
making much easier and more accurate. As one
participant put it, “Knowing the exact clinical history
and intraoperative notes.” It helps them connect the dots
and see the full picture. On the other hand, when
information was missing, uncertainty increased. In those
situations, fellows often had to ll in the gaps by
requesting more imaging or discussing the case with
others.
Theme 3: Diagnostic Uncertainty
Fellows said that uncertainty is part of daily practice,
especially in complex imaging cases. They often found
it dicult to tell apart conditions tha t look similar on
imaging, particularly in postoperative and vascular
cases. For example, it can be challenging to distinguish
haemorrhage from surgical material or endoleak from a
penetrating ulcer. The uncertainty is even worse when
the imaging is inadequate. Fellows often face uncertainty
because dierent conditions can look alike on imaging,
so they consider several possible diagnoses before
concluding.
Theme 4: Decision-Making Under Pressure
Fellows said they often work in high-pressure situations,
especially when dealing with unstable patients. In these
cases, they have to make decisions quickly, even when
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enough information is not available. There is little time
to pause, so they have to think on their feet and make a
quick decision. This creates a clear tension and tests their
nerves. On one hand, they want to be certain about the
diagnosis. On the other, they cannot aord to delay
treatment. As a result, they often have to balance speed
with accuracy and make the best possible decision with
what they have. Fellows often make quick decisions in
urgent situations, even without full information,
balancing the need to act fast with the need to be
accurate.
Theme 5: Learning Through Experience
Fellows said that experience is key to building
confidence and improving decision-making. They
learned over time through several ways: Seeing more
cases, which helped them recognise patterns; and reading
the literature to strengthen their knowledge. Getting
feedback from consultants helped them correct mistakes
and improve over time; this learning helped them nd
their feet and feel more comfortable handling dicult
cases. They became better at dealing with uncertainty
and more condent in making decisions on their own.
Fellows become more condent and better at making
decisions as they gain experience, learn from cases, and
receive feedback.
DISCUSSION
This qualitative study points out several critical factors
that inuence clinical decision-making in cardiothoracic
radiology despite limited sample size. Our findings show
that clinical decision-making is not solely based on
imaging, but is shaped by a combination of clinical
information, consultant support, experience, and the
ability to manage uncertainty, often in crucial time-
sensitive and acute situations. Fellows described
depending on accurate clinical history and operative
details to interpret imaging correctly, especially in
postoperative studies, while also seeking input from
consultants and multidisciplinary teams to improve
confidence and reduce errors in diagnosis. Uncertainty
was a common feature, and all fellows reported a certain
level of uncertainty, particularly in complex
postoperative and vascular cases, where multiple
dierential diagnoses had to be considered at the same
time. In addition, participants reported working under
pressure, where rapid decisions were required despite
incomplete or insucient information, highlighting the
balance between diagnostic certainty and timely
intervention. These ndings are consistent with the work
of Mastrodicasa D et al., which emphasises the value of
integrating imaging with clinical context and working
within a multidisciplinary environment.
7
Repeated
exposures to complex cases helps fellows improve their
clinical reasoning and recognise imaging patterns more
confidently. This may reect dual-process theory, where
familiar cases are recognised more rapidly through
pattern recognition, while dicult or unfamiliar cases
require slower and more careful thinking. They also
learn by observing how experienced supervisors
approach difficult cases and reach a diagnosis. However,
when cases are unfamiliar or uncertain, senior support
remains important. The study also supports the idea that
experience and ongoing learning play a key role in
developing condence and gradual independent
support, clinical context, and experience. Access to
decision-making. Overall, this suggests that decision-
making in cardiothoracic radiology is a complex and
evolving process that depends on both individual
judgement, learning and eective teamwork. Seeking
consultant input in dubious cases remains an important
component of safe clinical practice in radiology. The
review by Manoel PZ et al. describes how modern
cardiovascular imaging is increasingly incorporated with
clinical data to support more precise and bespoke patient
care.
8
This reects our ndings that accurate clinical
information is essential for interpreting imaging and
improving diagnostic condence in reporting. The
review also highlights the use of advanced technologies
and quantitative imaging in making more structured and
accurate reports. However, despite these advances, the
need for clinical judgement, experience, and
multidisciplinary feedback remains central. This
supports our observation that decision-making in
cardiothoracic radiology continues to depend on a
balance between technology, clinical context, and
human experience. Uncertainty is a fundamental part of
radiology reports rather than a reection of inadequate
knowledge. It can be attributed to many factors,
including technical diculties and si milar imaging
features. Bruno et al. demonstrate how imaging
interpretation often involves vagueness due to
overlapping imaging ndings, making uncertainty a
central feature of radiological practice.
9
Similarly,
Littlefair et al. stresses that radiology decision-making
frequently occurs in situations where complete certainty
is not possible.
10
This aligns with our results and themes,
where fellows reported diculty distinguishing between
similar imaging features despite having adequate
knowledge. Together, this suggests that complexity in
cardiothoracic imaging arises mainly from the nature of
the imaging itself, requiring clinicians to manage
uncertainty and consider multiple possible diagnoses
rather than simply applying factual knowledge.
Adequate clinical information and multidisciplinary
input help in these cases. Fellows trust a combination of
support systems, clinical context, and experiential
learning to navigate this uncertainty. Consultant
supervision emerged as a key factor, reecting the
importance of mentorship in clinical training and
fellowship. Fellows do not remove uncertainty, but they
learn to manage it efciently through a combination of
Interpreting Complexity: How Senior Clinical Fellows Approach
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J Gandhara Med Dent Sci
October - December 2026
senior input helps reduce doubt and avoid errors.
Mentorship has been shown to support radiological
professional development by providing guidance,
feedback, and reassurance during uncertain
situations.
11,12
The study by Zavala Calahorrano A et al.
highlights that clinicians often work in active and
uncertain situations, where time pressures, workload and
incomplete information increase the risk of errors.
13
Similarly, the systematic review by Carrie Reale et al.
highlights that during stressful times, clinical decision-
making is affected by stress, cognitive load, and
situational complexity.
14
These studies support our
findings that fellows frequently make rapid decisions in
urgent scenarios while balancing the need for accuracy
with the requirement for timely intervention. Both
studies also highlight the importance of experience,
teamwork, and structured support systems in reducing
error and improving overall outcomes. Both studies also
highlight the importance of experience, teamwork, and
structured support systems in reducing errors, mistakes
and improving overall outcomes. This also links to
cognitive load theory. Complex cases require fellows to
consider several pieces of information at the same time.
When this happens under time pressure, decision-
making can become more dicult. Research studies
show that as trainees progress from junior to senior
stages, their condence and ability to make independent
decisions improve, reecting increased clinical exposure
and responsibility. Colarieti et al. state that perceived
autonomy and readiness increase with training and
extended experience. These are closely related to the
quality of mentorship and education.
15
Similarly, Vieira
et al. and Fagan et al. emphasise that mentorship
provides essential guidance, feedback, and support
during uncertain situations, helping trainees bridge the
gap between knowledge and practice. These ndings
strengthen the view that the transition from supervised to
independent decision-making, like from trainee to a
consultant, is a gradual process shaped by experience,
structured training, and eective mentorship.
11,12,18
These ndings can also be understood through situated
learning theory, which suggests that learning develops
through active participation in everyday clinical practice.
For fellows, working within the clinical team and taking
increasing responsibility may support their gradual
development towards independent practice. This study
highlights that clinical decision-making in
cardiothoracic radiology is a complex process shaped by
uncertainty, clinical background, consultant support
systems, and clinical experience. Fellows do not rely on
a single factor but use a combination of basic knowledge,
senior mentorship, and repeated exposure to similar
cases to make safe and eective decisions. As training
progresses, there is a clear shift from dependence on
supervision to greater independence, supported by
growing condence, experience and pattern recognition.
These ndings are consistent with the work of Berner ES
and Graber ML, who highlight that both cognitive
processes and system-level factors, including experience
and clinical support systems, inuence clinical decision-
making.
16,17
Overall, improving decision-making in
cardiothoracic radiology requires not only advanced
imaging tools but also strong, committed training
environments, eective mentorship, and recognition of
uncertainty as a core part of clinical practice.
LIMITATION
A small sample size and single-centre design limited the
study. Self-reported data may introduce recall bias.
Future studies with larger samples and other
methodological approaches may provide broader
insights.
CONCLUSION
This study highlights that interpreting complex
cardiothoracic imaging requires more than image
recognition alone. Clinical information, diagnostic
uncertainty, time pressure, experience, mentorship and
senior support all these factors inuence clinical
reasoning and decision-making. With increasing case
exposure, feedback and mentorship, fellows develop
greater condence and independence. Ultimately,
experience builds condence, but knowing when to seek
support remains an important part of clinical expertise
and patient safety.
CONFLICT OF INTEREST:
None
FUNDING SOURCES: None
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Khalid Shakeel Babar
-
Concept & Design; Data Acquisition;
Data Analysis/Interpretation; Drafting Manuscript;
Critical
Revision; Supervision; Final Approval
Junaid
Sarfraz
Khan
-
Concept & Design; Drafting Manuscript;
Critical Revision; Supervision; Final Approval
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Interpreting Complexity: How Senior Clinical Fellows Approach
