The Typical Radiologist Work-Day

This is the kind of article that should be completely free, but is unfortunately behind a paywall . This article by Dhanoa D et al in the J of the American College of Radiology tracks the typical workday or hospital radiologists in 3 hospitals in British Columbia in Canada and not surprisingly comes up with final conclusion, though they don’t use these words per se, “radiologists are not image-readers – they are physicians who are actively involved in patient management using tools of image interpretation and intervention”.

For those of you who want a copy, email me or leave a comment with your email ID and I will send you the article.

The take-home points are:

  • Local on-site radiologists spend 36.4% of their clinical time on image interpretation.
  • 43.8% of on-site radiologists’ clinical time is spent on noninterpretative activities, such as quality assurance tasks, patient safety responsibilities, and image-guided procedures.
  • The total clinical productivity of on-site radiologists is 87.7%.
  • On-site radiologists experience an average of 6 inter- actions per hour with health care personnel, of which 81.2% directly influence patient care in the medical imaging department.
  • Replacing the on-site radiologist discounts the value of their noninterpretative activities, suggesting a loss to the provision of high-quality patient care. 

Essentially, an on-site radiologist is critical to patient management.

This would even translate to diagnostic centers, where even though there is reduced direct interaction with treating physicans and surgeons, the amount of time spent on the phone or other methods of communication interacting with referring doctors with respect to appointments, scheduling the correct study for the correct clinical situation, monitoring studies, contacting the doctors with provisional and final reports and ensuring proper patient flow, as well as dealing directly with patient queries, etc. takes up a significant amount of time. At best, even in an optimized private practice workflow situation, a radiologist is unlikely to spend more than 50% of his/her time actively looking at images.

 

Thyroid Ultrasound Criteria to Diagnose Possible Malignant Tumors

There are so many important articles that do not get published in the radiology literature.

The recent issue of JAMA Internal Medicine has an article by Smith-Bindman R et al that discusses how to use thyroid USG signs to decide which nodules need to be biopsied.

Three criteria are important – microcalcifications, completely solid appearance and size greater than 2 cm. If we stringently follow the rule that at least two of these criteria have to be present before performing thyroid nodule biopsy, then the sensitivity would be reduced but with a high positive predictive value, but without compromising the ability to pick up malignancy. It is worth reading the article to understand the importance of large population based studies to help us use our radiology signs to better triage patients.

 

Social Media and Doctors

This is an interesting article in the recent JAMA by Lerner B discussing what is appropriate and what is not as far as the use of social media in medicine is concerned, especially at the level of resident doctors.

Not friending patients, not posting compromising pictures online, not discussing inappropriate issues including sexual and otherwise are standard, quite obvious points that need to be followed by all.

Moderate Sedation by Radiologists

There is a review article in in the November issue of the AJR by Olsen et al, discussing the various types of sedation and options available if radiologists want to perform their own analgesia, especially when it comes to moderate sedation (earlier called conscious sedation). This article is predominantly aimed at North American radiologists and specifically the context of their practice.

While I used to deliver moderate sedation on my own up to a couple of years ago, especially in patients who needed bone biopsies, I now no longer do so myself. I always have an anesthesiologist stand-by, simply because delivering and monitoring of the sedation adds another layer of stress and actually affects my ability to perform the biopsy / procedure optimally. If there is an adverse event, again, it is better to have another pair of experienced hands that can take the load off your back and allow you to focus on more important things.

Sub-centimeter Lung Nodule Biopsies

This article from the November issue of the American Journal of Roentgenology discusses the results of 305 CT guided core biopsies / aspirations of small lung nodules, less than 1.0 cm in diameter, over 13 years.

The only major variable that decided success was aspiration instead of core biopsy.

I have been very clear about doing core biopsies for lesions in the body as against FNAC / aspiration for many years now. Tissue today is needed for so much more than just establishing a diagnosis that if we are going to put a needle in the lungs, or other parts of the body, it would be a travesty to come away with only cells, without tissue.

Here is an example of a 7.5 mm lung nodule biopsied earlier this year that turned out to be tuberculosis on histopathology.

Biopsy of 7.5 mm lung nodule

Biopsy of 7.5 mm lung nodule

Communication with Patients in Radiology

This has always been a sticky subject.

As a rule, we are encouraged not to communicate radiology reports directly to the patient, but preferably through the referring doctor, who apparently knows better the clinical relevance of the findings. Hence typically we restrict ourselves to giving good news to patients, when their scans are normal, or lesions have improved, but prefer to hide behind the veil of “your treating doctor knows better”, when the findings will have a significant impact on the patient and his/her management.

Amber and Fiester have addressed this beautifully in the March issue of the AJR and taken this subject head-on. They are very categorical that “In this new paradigm, we argue that it is an ethical duty of the radiologist to communicate results to all patients who desire that information.”

I completely agree. If we want to stay relevant, then we need to interact with our patients more and more. This has already been happening with ultrasound, because, unlike in the US, we radiologists in India and similar countries directly interact with our patients while doing ultrasound and can’t escape talking to the patients and discussing findings. We need to take this ahead with CT, MRI and x-rays as well.

In the November 2013 issue, Dr. Saurabh Jha has a tongue-in-cheek letter-to-the-editor, which is also quite interesting and worth a read because of the reality check and practical questions he poses.

Empathy in Radiology

Everything that we have been discussing about empathy in radiology is discussed in such detail by Dr. Richard Gunderman in the latest issue of Radiology.

I recently had to give a “shidori” lecture to the 1st MBBS batch that has just entered G S Medical College. The whole focus was on empathy and respect for patients…radiologists or otherwise…all doctors need to cultivate this to be successful practitioners.

 

 

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