The Physician Buried Inside the Radiologist

I received this from Dr. Akhila Prasad, Sr. Specialist, Dr. RML Hospital, New Delhi. You can reach her at akhil43 at yahoo.com

“I came across your new blog. It is very thought provoking and has encouraged me to share a similar 15-years old story.

I was a resident in radiology working in a busy 1500-bedded Govt. Hospital in Delhi. You can very well imagine the pressure of work we were under. It was one such busy morning with the USG room swarming with patients. There is this general “known to” syndrome that we all have to deal with, especially in a free service Govt. Hospital. I had to handle a request from a distant friend of my husband who had referred his office peon and his three-years old daughter, who had been asked to get an X-ray done of the spine by some general physician (GP) as she had had a fall and needed to be take care off, since they were poor.

I readily said yes and when he presented the GP’s requisition form and my friend’s letter of recommendation, I very conveniently and quite mechanically picked up an X-ray form and ordered X-rays for the same, without really applying my mind. It was actually “one down” for me, so that I could take up the “next”! (in the never ending crowded room full of patients).

The man promptly came back after an hour or so with the X-ray plates for me to see, which to my cursory glance was a normal dorsolumbar spine. I was ready to pack him off, in my mind thinking, “Ok, my job is over”!

The man lingered on, pointing to his daughter’s back, saying, “Jab se yeh giri hai, isko yahan soojan saa hai, please aap iske peet ka USG kar deejiye.” (Since she has fallen, she has had a swelling in her back and can you please do her USG?) I was ready to snap at him saying, “peet ka USG nahi hota, aap yeh X-ray apne doctor ko dikha deejiye, yeh normal hai”. (We don’t do USGs of the back. Please go and show this X-ray to your doctor). I couldn’t really see any “soojan” (swelling) there on a cursory inspection.

Something made him persist and insist that I should see his daughter’s back with USG. A father’s heart perhaps…something made me comply to what at that time sounded like an unreasonable, illogical request…a mother’s heart perhaps! His daughter though from an entirely different social strata, somewhere somehow probably reminded me of my own three-years old….

Just to get him off my back, I put a probe on her abdomen and received a nasty shock! There was a large retroperitoneal mass crossing the midline and displacing the aorta anteriorly. Though there was no swelling where the father had indicated on the back, there was this mass, unknown to him in the front.

The next steps were a complete haze to my numb resident brain. I rapidly went ahead with a contrast-enhanced CT scan and an MRI in the next two days, involved the pediatric surgeon, got all the “free sanction” formalities done that a poor patient is entitled to in our Govt. Hospital and quickly got a tissue diagnosis of neuroblastoma, adequately staged!

Next came the hurdle of treatment and the pediatric surgeon was kind enough to refer and recommend the case to her colleague at the All India Institute of Medical Sciences (AIIMS) for free treatment (chemotherapy and pediatric oncosurgery are not available in our hospital) and the girl was quickly enrolled in for chemotherapy followed by surgery. To cut a long three-years story short, she was fully treated and went into complete remission!

In all this, the girl’s father remained truly grateful and extremely indebted to me, thanking me at every step and very religiously following every medical step and going through whatever that was required of him as the father of the child. Little did he realize how close I had come to miss the lesion!

Just because he came through an indirect private GP’s referral as a “known to” and as a “favor” that I had to finish off as part of that day’s hurly burly, with the attitude that it was not my job to go the extra mile or do an USG since I am a radiologist and not a clinician and I had done my job by getting the X-rays done…how horribly wrong such a line of thinking would have been!

A timely diagnosis, quick efficient work up, jumping the queue in a Govt. set up, taking care of the cost factor, quickly putting the ball into the concerned clinician’s court, the right form of therapy quickly initiated and followed up, with the diligent persistent co-operation of the child’s father…all worked wonders!

But even to this day, it sends a chill down my spine when I realize how close I had come to miss the pathology! As to how I would have been personally responsible for this child’s demise had it gone undetected!

It would still have been easy to justify…for all you know I would not even have come to know of the subsequent events, as that man hardly mattered in my life…the disease would have taken its own time to appear. You can say it was never my primary responsibility as a radiologist…but that is not the point! The point is there was a moral responsibility! There was the moral and ethical responsibility that I had as a doctor, forget as a radiologist, but just as a basic MBBS doctor, as a physician buried in every radiologist that I needed to exercise to take care of the faith and trust that the father had reposed it me.

And how horribly I would have shattered that trust had I not come up to the basic expectation of a common man.

To this day, he looks upon me as someone great who has saved his child. She is a strapping young woman all of 13, the same age as my daughter. In fact during the early years of treatment, he in all his gratitude would deliver fresh eggs produced out of his “murgis” (hens) that he was rearing to provide extra nourishment to his daughter! And he would bring those few eggs for my daughter.

He has unknowingly taught me valuable lessons that I learnt, thankfully the hard but not the harsh way, luckily early in my career, lessons that have stayed with me ever since…lessons to pass on to all newcomers….

1. Every X-ray or CT or MRI you report is not a film but a person. A live, breathing, living, thriving person with a story behind him or her, a puzzle or a mystery to be solved, sometimes a “Pandora’s box” waiting to be opened!

2. You may view yourself as “just a Radiologist”, and believe that it is the clinician’s job to solve the jigsaw puzzle…but the patient who is so trustingly lying in front of you or the attendant who is so anxiously peering down the unintelligible films that you are reading in front of him, doesn’t think that!

FOR HIM, AT THAT MOMENT YOU ARE HOLDING THE KEY TO THE LOCK!

You owe it to him to at least not shatter his blind trust!

3. Sometimes, many a times, the normal procedure of the patient first going to the clinician, and then the clinician ordering a particular radiology test is bypassed! You as a radiologist may be the first point of contact for the patient! And they believe you are God.

SO THE ONUS IS ON YOU!

YOU HAVE TO GO THAT EXTRA MILE!

Yes, you can always say, “It is not my domain, I don’t know”! But you should do that AFTER you have done YOUR bit. And after you have shown him the right path to take.

4. That the patient is too poor and you are actually doing him a great favor by doing this much for him in a free Govt. hospital, does NOT give you the right to be casual, lackadaisical or lethargic and show clinical inertia, or should I say “Radiological” inertia. In this case, my initial horrible first reaction was, “Ok, such a heavy day, such an indirect “known to” referral and he is being so fussy even though there is nothing in the case.” How horribly wrong I would have been if I had followed my first reaction!

Inside every radiologist lies a physician.

Don’t let him or her die!

The Making of a Good Radiologist Today!

This week’s New England Journal of Medicine (NEJM) has an article titled “Holistic Review – Shaping the Medical Profession One Applicant at a Time” that describes how some medical colleges in the US are now assessing medicine applicants more holistically than just on their academic grades. This allows the selection of candidates who will have not only the knowledge required to practice medicine, but the ability to communicate better with patients, to work in teams and to deliver better all-round care.

A similar article by Dr. Pauline Chen in 2010, in the New York Times, describes what the “right stuff” to be a doctor and also the importance and use of personality tests to predict how students will perform as physicians. Recently, she has written another similar article that discusses a medical student who was very good with her knowledge but had poor communication skills and an inability to get along with her colleagues and peers, but couldn’t be “flunked” for these shortcomings.

A comment by Dr. Deniz Ones, in the 2010 article by Dr. Chen is very interesting, ““If a medical school is all about graduating great researchers, then I would tell them not to weigh the results of the personality test that heavily…But if you want doctors who are practitioners, valued members in terms of serving greater public, then you have to pay close attention to these results.”

This also applies to radiologists. If being a radiologist was only about reading images on a workstation or view-boxes without patient interaction, then all that we would require is knowledge and the ability to work fast, accurately and to deliver quick turn-around times.

But that is not what being a radiologist is about. I had addressed this issue partly in an editorial in the Indian Journal of Radiology & Imaging in 2008, where I summarized “All our radiology reports need to answer the ‘why’ question. To do this, we must be thorough with our understanding of the clinical situation and the answers being sought by our clinical colleagues. For this to happen well, we must subspecialize and be able to speak the same language as our clinical colleagues. Subspecialization inherently means that we need to work with other radiology subspecialists in a group practice; both academically and in general, this would automatically lead to a better quality of life.”

A good radiologist has the ability to deliver results accurately and in a timely manner. Dr. Woodcock in a short article distils this into the three “A”s of Affability, Availability and Accuracy. The Royal College of Radiology has specific guidelines. It also means not shying away from leadership positions in hospitals and practices and actual patient consultations.

In the end, as radiologists we must realize that as radiology becomes more and more important to patient management in many disciplines, we have the unique opportunity and ability to be a part of and perhaps in many situations the pivots that can make a difference…this involves moving away from the workstations and view-boxes and interacting more and more with patients, other radiologists and our physician and surgeon colleagues. And apart from knowledge, this also requires us to have good communication skills, bedside manners and empathy.

When Procedures Make Intuitive Sense, Despite the Data (or Lack of)…About IVC Filters and Vertebroplasty

Today’s (April 08, 2013) issue of JAMA Internal Medicine brings forth a new controversy regarding another common and popular interventional radiology procedure  – retrievable IVC filter placement.

A review of data in a new retrospective study on the efficacy of IVC filters, has shown that there is only one randomized control trial published in 1998 that showed a reduction in the rate of symptomatic pulmonary embolism in those with filters but with no significant long-term difference in the death rate at 8 years and with an increase in the rate of deep vein thrombosis in those who had filters.

This new retrospective study published in JAMA Internal Medicine concludes, “that the use of IVC filters for prophylaxis and treatment of venous thrombotic events, combined with a low retrieval rate and inconsistent use of anticoagulant therapy, results in suboptimal outcomes due to high rates of venous thromboembolism”

Another study in the same issue discusses the differing rates of use of this technique in California, the main factor being the particular hospital that is providing care. The Society of Interventional Radiology guidelines [4] for the use of an IVC filter list four absolute indications – “recurrent VTE (acute or chronic) despite adequate anticoagulation, contraindication to anticoagulation, complication of anticoagulation, inability to achieve/maintain therapeutic anticoagulation”.  However there is a long list of relative indications with little consensus and that is where there is significant variability, depending on the aggressiveness of the program.

It happened with vertebroplasty when two studies by Kallmes et al and Buchbinder et al, comparing sham procedures with actual procedures showed no significant difference in pain scores between the two groups at all time points. This kicked up a huge storm in the interventional radiology and spine communities, but also forced us to examine our data more objectively and spurred more hospitals and groups to perform their own double-blind control studies, a few of which like the Vertos II trial, have shown that vertebroplasty is better than controlled medical treatment, though there has been no comparison with sham procedures since the 2009 studies.

We all want to believe that “doing” something that is intuitive (cement in an acute fracture, IVC filter stopping downstream emboli) has to help, just like Dr. Zamboni’s belief in treating patients with multiple sclerosis by dilating areas of venous narrowing because of the theory he ascribes to that chronic cerebrospinal venous insufficiency is the cause of multiple sclerosis.

Procedures sometimes quickly become mainstream without data, simply because “they make sense”. Cardiac CT angiography found adopters in patients and celebrities like Oprah Winfrey, simply because it made sense to see the coronary arteries without a catheter, despite the lack of any kind of initial data.

In the end though, we as radiologists need to create compelling stories for the use of techniques, modalities and procedures by making sure that there are enough controlled studies that demonstrate efficacy and safety.

Hopefully in the near to medium future, there will be more date regarding the efficacy (or not) of IVC filters that will clear the air and help patients and the treating doctors make better decisions.

Primary Prevention of Cardiovascular Disease with a Mediterranean Diet — NEJM

As radiologists, while it is important to know our radiology signs and methods of interpretation, a little knowledge of what is happening in the rest of the medical field doesn’t hurt, especially when patients these days often seem better informed.

Today, this study has been published in the current issue of NEJM. There were three groups, two with Mediterranean diets and one control group without. The two groups with the Mediterranean diets along with olive oil and mixed nut (walnuts, almonds and hazelnuts) supplements showed a significant reduction in cardiovascular risk and events over 5 years.

Primary Prevention of Cardiovascular Disease with a Mediterranean Diet — NEJM.

Persistence Pays with Hard Bones And Nuts

This story has been contributed by Dr. Argha Chatterjee, a third year PG in the department of Radiology at the Medical College and Hospital, Kolkata, after reading the earlier post on Tea and Fluorosis and in the spirit of this blog.

In his words…

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This is the story of a 28 year old gentleman, who presented to the general medicine out-patient department (OPD) with stiffness in both knees and spine for 2 years. He could not walk and was carried to the OPD by his neighbour. His knees were fixed at flexion and he had significant kyphosis. The doctors at the medicine OPD saw his knee radiographs done elsewhere, which showed gross osteopenia and a coarse trabecular pattern. The patient was admitted and radiographs of his knees, pelvis and lumbosacral spine were performed in our department.

A medicine post-graduate trainee (PGT) took away the “wet” films (it was a digital radiograph, so not really “wet”) and so it never came to us for reporting. After two days the radiographs were brought to our department by another medicine PGT. They were obviously confused because the pelvic and spine radiographs showed marked high bone density. They thought ofosteopetrosis but could not explain the osteopenia in the knees. They wanted to know what sclerosing bony dysplasia can cause both. In the meantime, the history had already taken a back seat.

What I saw was grossly increased bone density in the pelvis and lower lumbar spine associated with calcification and, at places, ossification at the ligamentous attachments (Figure 1). The knees showed osteoporosis, especially in the lower end of the femur (Figure 2). Calcification of the obturator membranes was present (Figure 3). There was coarsening of the trabeculae in all the visualised bones. Now, this is supposed to be a long case in the MD examination. So I said, “This is fluorosis.”

Frontal radiograph of the pelvis shows increased bone density and calcification at the ligamentous attachments (arrowheads).

Frontal radiograph of the pelvis shows increased bone density and calcification at the ligamentous attachments (arrowheads).

Frontal radiographs of both knees (fixed at flexion) show coarsening of the trabeculae and osteopenia at the lower ends of both femora.

Frontal radiographs of both knees (fixed at flexion) show coarsening of the trabeculae and osteopenia at the lower ends of both femora.

Oblique radiograph of the pelvis shows obturator membrane calcification (arrow).

Oblique radiograph of the pelvis shows obturator membrane calcification (arrow).

The PGT was not convinced. He argued for ostepetrosis. I countered that this was not dysplastic bone because the trabeculae were coarse; moreover the osteopenia and joint stiffness could not be explained by a dysplasia. He argued about the presence of coexistent osteopeia? I explained to him that osteoporosis is a known and important feature of skeletal fluorosis. In fluorosis, there is increased bone turnover. So initially there is high bone density (phase I) but later on, the long bones develop osteoporosis (phase II). He asked, “Isn’t there interosseous ligament calcification in fluorosis?” I pointed out the obturator membranes (Figure 3) and lesser trochanters. He said that his boss was not going to be convinced by just that. I agreed to arrange for a forearm radiograph free of cost.

The next morning I visited the patient’s bedside after reading up the clinical features of fluorosis. The patient had every feature. The stiffness started in the spine until he was finally immobile from knee stiffness. The PGT was there with a grin on his face. He said, “This is not fluorosis. The patient has no dental changes. I checked.”  I said that dental fluorosis occurs only when patient is exposed to high fluorine levels during the pre-eruptive stage of teeth. Then he dropped the bomb. “He is from Serampore, Hoogly!” Now this one floored me. The districts of West Bengal endemic for fluorosis are Purulia, Birbhum, Malda, Dinajpurs and South 24 PGs. Not Hoogly. I anyway asked for the forearm radiographs which were done later that evening. The forearm radiographs were classical for fluorosis (Figure 4).

Frontal radiographs of both forearm show classic interosseous membrane calcification (arrows).

Frontal radiographs of both forearm show classic interosseous membrane calcification (arrows).

Nevertheless the medicine unit did become serious about the diagnosis of fluorosis. A urine fluoride was done within the coming week but surprisingly it was normal. I thought my spot diagnosis was slipping away. About 2 weeks later, I met the same PGT in the canteen. I asked him about the case. He said a drinking water sample from the patient’s home was tested in a lab at Jadavpur University. The fluorine level was 2.5 mg/litre (WHO guideline value is less than 1.5 mg/litre). “The urine level?”, I asked. He told me that if a person is more than three weeks away from exposure, then the urine level may become normal. They finally diagnosed the case as skeletal fluorosis. He also told me that people at JU were surprised to find such high fluoride levels in Serampore.

I realised that day how important radiology can be in clinical diagnosis, sometimes against other evidence and we are, indeed, clinicians, not just image readers.

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For a comprehensive review of the radiology of skeletal fluorosis, please read this article.

Arghat’s contact: arghachat84 at gmail.com

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