Why did the Potter’s Hand shake?

One more piece from Dr. Akhila Prasad, Sr. Specialist, Dr. RML Hospital, New Delhi that makes her think. You can reach her at akhil43 at yahoo.com. She earlier wrote the piece, “The Physician Buried Inside the Radiologist”.

 

A vessel of more ungainly make…

What! Did the Hand then of the Potter shake?

The Rubaiyat of Omar Khayyam.

 

Who among us radiologists, are not familiar with the sickening, sinking feeling we get when we are scanning a blissfully, happily pregnant woman’s abdomen and the various shades of grey slowly reveal to us, “Yes! The Potter’s Hand must have shaken while making this pot!”

This is about the number of times we have diagnosed some form of congenital anomaly on an antenatal scan! The mother is smiling and looking at us in anticipation, often in a blissfully ignorant, content state, lying in front of us, so trustingly exposing her pregnant belly carrying that magical life inside her!

We have to continue to maintain a poker face as if nothing is amiss and everything is fine and first try to figure out what the hell is happening on the screen, and having quickly figured out how the Potter’s Hand shook and having frozen all the shakings into eternity (images), comes the next issue of how to tell, what to tell and how to manage the patient!

Sometimes the patient guesses even before we say something, our body language perhaps or the facial expression or her own intuition…or the number of postgraduate students excited beyond imagination at the unimaginable cosmic mistake in front of them!

Thoughts of all kinds, all at the same moment, fleet past in our minds…to err is human, but here is where the Divine seems to have erred! Is it possible? How? But the results are in the front of us on the screen! “What was that unborn child’s fault dammit!” you ask yourself. It has not even come into this world yet, or committed any mistake and it has had to pay…like this?” your brain argues. “Karmic”, the word echoes somewhere in your brain, a general one-stop shop answer to every Indian problem! “Whose Karma?” immediately your brain asks. “The unborn body? Or the unborn soul? Or the previous birth body? Or the previous birth soul??…you don’t have any answers!

And by that time anyway you have more pressing problems at hand to handle! To handle the patient at hand! To handle her mother or husband standing next to you! To gently reveal to them that something is wrong! God forgot to put a head! Or He shortened a couple of limbs! He decided to put the baby’s abdomen into the chest! God!!! What do you say? How do you say it? And why doesn’t it get easier over the years? Why is it as troubling and as painful each time? And the irony is that despite what you feel inside, you automatically tend to stick to your professional training and duty and deal with it as if it is perfectly normal to have an abnormal unborn child. And so you write out the report and say, “Next!”

This brings us to one more core issue in our training. We must drill it into every resident’s head to mentally and morally treat every obstetric ultrasound after the relevant period of gestation, as a Level II study! The patient has come to us at this instance for a scan, after fighting God knows what odds and under what difficult circumstances. It does not matter whether the ultrasound form or receipt says, “Level II”! We have to scan her child head to toe, no matter what the form says, no matter whether it is her nth ultrasound…it has to seep into our very being, that we have to quickly and systematically declare normalcy or detect anything abnormal. The mother and the child both deserve that!

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.

Radiologist – patient interaction

Radiologist – patient interaction

Ultrasonologists interact with their patients, which is why after a certain number of years, they can actually create a “direct” practice, without referrals.

For those who work with X-rays, CT scan, MRI and PET, the patient interaction, especially after the study is done and when it comes to communicating the report is very limited. Perhaps, the time has come to address this? To actually build in some consultation time if patients want to discuss the findings on their scans?

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