The Master Surgeons

Dr. Pauline Chen as a piece in the NY Times about how the skill of a surgeon makes a huge difference, but has always been difficult to measure.

And yet, by word of mouth, it has always been possible to know of surgeons who are “amazing”, “lightning fast” and “gifted”. The anesthetists, nurses and resident surgeons are in the best possible position to compare and evaluate, along with the surgical ICU doctors. This knowledge obviously rarely gets passed on to patients.

It is the same in radiology. All radiologists are not and can never be the same, which is why radiology cannot be commoditized or “teleradiologized”. And over a period of time, everyone in the community knows who the brilliant ones are, both from a diagnostic as well as an interventional perspective. The patients may never come to know.

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.

 

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.

The role of a radiologist – gatekeeper v/s service-provider

Dr. Saurabh Jha has a very interesting article in a recent issue of The New England Journal of Medicine, discussing the role of a radiologist.

In the UK, where he trained, it was that of a gatekeeper. In the US, it is that of a service provider.

In India, we are predominantly service providers and perhaps less than 5% of the work we do allows us to act as consultant physicians, advising on what next is to be done or on the appropriate modality to be used.

Does it work!

In a recent issue of JAMA, there is an editorial of whether injection therapy for low back pain works. An evaluation of previous randomised trials and a meta-analysis shows that there is no clinically significant evidence that this works. And yet, we have an entire new field of pain management populated by anesthesiologists in particular but also radiologists and orthopedic surgeons, who specialise in injecting into the epidural space, facets and foramina. A cursory Pubmed review will show a large number of articles on this subject discussing technique and the value of one particular steroid over another….when in reality the efficacy of the very concept of injecting in the spine for pain management is questionable.

This is similar to the vertebroplasty controversy that still really hasn’t died, but for all practical purposes has been subverted by those who practice vertebroplasty so that the procedure can continue to be used across board.

The New York Times last week published a blog based on a recent article in the Mayo Clinic Proceedings that showed how doctors continue to use procedures and therapies that may be ineffective or may even harm patients. This is either due to ignorance or inertia, but in the period that the practice continues, harm continues to be done.

While all of us itch to “do something” each time a patient has a problem, we should constantly be asking ourselves, whether the procedures we perform and the therapies we use, actually work!

Have you followed-up this patient?

This is a post by Dr. Anisha Sawkar. You can reach her here.

The question my residents dread:  “Have you followed up on that patient?”

I work in a teaching hospital and am one of the fortunate few who have residents do a lot of my work for me. Typically, as in a lot of teaching hospitals, the residents make the first draft of a report that is then checked by the consultant. This enables teaching and hopefully, the residents learn from the changes the consultants make and the subsequent interaction that helps them separate right or wrong.

This learning will obviously be helpful but does not compare with the kind of permanent learning that will result when they follow up the patient and confirm the diagnosis that was given. Residents need to remember that we are not infallible and what we said cannot be the gospel truth. The ultimate learning will only come with the “follow-up”. The habit of following up on patients needs to be inculcated in residents during their formative years and this habit will only be practiced if they see their seniors do the same. The example will only be set if they observe that at least in difficult or ambiguous cases, their consultants go out of their way to contact the referring physician/surgeon just to find out how the patient is doing.

In a busy chaotic 2000 plus bed teaching hospital and tertiary health care center, obtaining a follow up on a patient is not always easy, and therein lies the other aspect of the story. If we maintain a close working relationship with our referring colleagues, not only will our follow-ups become easier and forthcoming; the gratification of having made a difference or the humbling occurrence of having made a mistake will help us become better at what we do. And God knows, we need to be reminded of our limitations and learn from our mistakes. As Mahatma Gandhi beautifully said “It is unwise to be too sure of one’s own wisdom. It is healthy to be reminded that the strongest might weaken and the wisest might err.”

At the resident level, these close interpersonal ties with residents of other faculties will enable a much smoother working relationship that will be of enormous help on busy on-call nights…these harmonious working relationship will ultimately benefit the patient.  Not to mention the fact that they will learn from their mistakes on call and hopefully from ours too. I’d like to end by quoting Brandon Mull who wisely said, “Smart people learn from their mistakes. But the real sharp ones learn from the mistakes of others.”

So, my dear residents, if you’re reading this, next time you’re asked for a follow up, please don’t silently curse your senior.  It is, after all, one of the best ways you’re going to learn.

The Vanishing Art of Clinical Science – Hyposkilia

This has been written by Dr. Anisha Sawkar Tandon, a consultant radiologist at the St. John’s Medical College, Bengaluru. You can reach her at anisha.sawkar at gmail.com

I am a practicing radiologist. Over the past few years I have noticed a disturbing trend that threatens to destroy the very nature of medicine. I have been witnessing increasing referrals for radiological investigations even before a clinical history has been taken. We radiologists are familiar with the experience of having to report radiological studies with absolutely the bare minimum clinical history or the complete lack of it. But what has begun to shake me to the core is the fact that even when I have gotten back to the referring clinician for more information, there have been innumerable instances where they simply do not know more just because they have not really talked to the patient in detail, leave alone examined the patient.

Here is an example of one of the situations that I was confronted with when reporting an MRI of the brain of a 58-years old lady who was sent from the emergency department. The referral form mentioned, “Rule out cerebral venous thrombosis (CVT)”. These were the only words of “history” provided. The MRI brain not only had no signs of CVT, but there were some symmetric basal ganglia changes that favored a metabolic encephalopathy, likely related to chronic liver disease. Since the Emergency department is easily accessible with a phone call, I could immediately contact them and ask for more details.

At first, since their question was “rule out CVT”, I attempted to elicit some history related to CVT. The disturbing answer that I got was, “The patient basically has altered sensorium and since CVT is one of the conditions that could cause CVT, we just wanted to rule it out!” I tried to find out more about the altered sensorium and the information I got in response was, “She basically looks like a psychiatric case and also has diabetes and hypertension”. After obtaining this invaluable information, I explained my findings and requested them to assess whether the patient had some form of liver dysfunction since the findings were definitely “metabolic” and not “psychiatric”.

These events had occurred at 6 pm in the evening. The next day, when I decided to follow up on what had happened to my patient, I found this sequence of events that had unfolded after my MRI brain report. The patient, had, at 7 pm undergone an ultrasound of the abdomen, which showed cirrhosis of liver with portal hypertension and ascites and suspicious nodules in the liver. At 8 pm, the patient had undergone a CT scan of the abdomen that confirmed the cirrhosis with regenerative nodules, portal hypertension and ascites. Meanwhile the results of the liver function tests showed findings consistent with chronic liver disease and the patient was known to be HbsAg positive for 5 years. The next morning, a clinical examination by a gastroenterologist and neurologist concluded that the patient was, in fact, in hepatic encephalopathy.

If you analyze this case, it worked out beautifully for the radiologist. What else could a radiologist ask for? An MRI brain, an ultrasound abdomen and a triple phase CT scan of the abdomen in one patient in one evening! What about the patient though? It’s scary to think that not one, but all of the above investigations could have been avoided by just basic history taking and an adequate clinical examination.

I understand that in a busy ER, not every patient with altered sensorium is going to undergo a 30 minutes detailed neurological exam, but a 30 minutes exam wouldn’t be needed if the simple task of talking to the patient had been accomplished which would have brought out the known Hepatitis B status. Whenever I see this kind of situation, I am appalled at what medicine has come to. There are so many more such instances in which an ultrasound of the abdomen is the first time that a large laparotomy scar has been noticed, or an MRI brain study is the first time when a craniotomy has been discovered and the referring clinician has had no knowledge of the same. It’s a different situation when such cases have been directly referred by some remote village primary health center “(PHC) and then perhaps the lack of knowledge by the referring physician can be overlooked. But it’s acutely disturbing when these cases are referred by our own colleagues, specialists in their fields and the first person to touch the patient’s hurting abdomen is a radiologist.

As a radiologist who wishes her field to thrive, I should have no cause for complaint. But as a doctor and a clinical radiologist, I am concerned about the kind of medicine we practice today, where the end result is unnecessary investigations and ultimately a burden on the patient and the system.

I would like to end by quoting Sir Robert Hutchison who said the following words, which sadly are very pertinent today

“From inability to leave well alone; from too much zeal for the new and contempt for what is old; from putting knowledge before wisdom, science before art, and cleverness before common sense, from treating patients as cases, and from making the cure of the disease more grievous than the endurance of the same, Good Lord, deliver us.”

Radiologists – The Who, What, Where, When, Why and How

The April, 2013 issue of the American Journal of Roentgenology has an article by Dr. Richard Gunderman discussing the who, what, where, when, why and how of being a radiologist.

It is a must read for every radiology resident and perhaps every practicing radiologist as well.

 

The Trust of Our Colleagues

In a recent issue of JAMA, is a short article by Dr. H. Esterbrook Longmaid that describes a moment when the doctor makes a diagnosis of metastatic prostatic cancer in another doctor, who has been a mentor and a teacher. It makes poignant reading.

I am reminded of the number of times I have had to break the news of some disease or the other to a colleague or junior or senior / teacher. So often, these doctors, even though they may not refer patients themselves, choose us because of the faith they have in us…that we will do the best we can when we perform the test, that we will break the news to them in the best possible manner and most importantly, we will maintain confidentiality regarding the results.

Each time a doctor comes to us in this manner, it should be a matter of pride that one of our colleagues who could have gone to anyone, has chosen you or me to come to, over others. And we should do our best to never undermine this trust.

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