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.

 

 

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!

Encouraging patients to speak up

While we all have patients who are garrulous and discuss things that are completely out of context, the vast majority of patients just do not find it easy to ask all the questions that would help them with their problems. More importantly, a large number of them have no clue about the questions that they should be asking. In the end, all that people land up asking are questions like, “It is not dangerous, right?”, “What food should I eat?”, etc, which do not help either the doctor or the patient.

In a recent issue of JAMA, an article discusses this issue well. It also references a website setup by the Joint Commission that has resources that help patients with the questions that need to be asked. As professionals, we need to encourage patients to educate themselves and to be better informed – this helps us as well as the patients no end and makes for a much better relationship.

Of course, in one sense it turns around the “No turn-back” issue on its head as well, doesn’t it!

 

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.

Overdiagnosis – Pulmonary Thrombo-Embolism

This one is an eye-opener.

This editorial from British Medical Journal talks about the the issue of incidentalomas, which we as radiologists are aware of – lung nodules, adrenal nodules, breast lesions, etc.

What is less known is the issue of overdiagnosis. And as far the problem with pulmonary thrombo-embolism is concerned, I was quite unaware that a good number of subsegmental lesions do not need treatment, as described in this article in the same issue of the journal.

What does this mean for us? We cannot step down our ability to read thrombo-emboli. However, the treating physicians do need to make a judgement call on whether all of these patients need treatment or not.

The title of this series is “Too Much Medicine” and the article starts with the phrase “When a Test is Too Good..” All very interesting.

 

The Male Doctor and the Female Patient

This is cross-posted from my lay blog that showcases my Mumbai Mirror column.

Starting today, once a month or more frequently, I will also address the changing paradigms of the doctor-patient relationship.

Last month, a family physician’s name was dragged into the spotlight when a female patient of his cried “rape” after a consultation, where he and she were alone in the consulting room for some time while the receptionist sat outside and the husband went off to attend to some work.

This piece is not about the rape allegation or whether the doctor was wrong or has been wronged. The doctor however did make one mistake. He spent time alone with a female patient in his consulting room, with the door closed!

In today’s day and age, each male physician has to adhere to one zero-tolerance rule. “NEVER see a female patient alone, irrespective of age, without a female attendant or a relative in the same room”. NEVER, EVER!

We wear seatbelts to protect ourselves from injury. We exercise to ward-off ill health. Similarly, we need to take measures to prevent any incident that can possibly smear our name and reputation. There are many such potential volatile situations, but none more than seeing a female patient alone in the consulting room.

I am paranoid! I don’t even see female employees alone in my office, except for a few who I have known for donkeys’ years and even then only for short periods of time, or with the door of the office open. If I am doing appraisals, I actually have the manager wait just outside the door…if a female employee goes out crying for whatever reason, it needs to be understood that there was no personal or physical manhandling of any sort.

Similarly with patients! By staying alone in a room with a female patient, the male doctor exposes himself to the possibility of an allegation of inappropriate behavior. How difficult is it to have someone else in the room?

In our country, rarely do patients come alone. There is invariably an attendant, a relative or a friend with the patient (sometimes 4 or 5 of them). Have that person(s) stay in the room! It is very difficult to make a rape or abuse attempt stick when you are alone and the persons accusing you, many. Assuming for whatever reason that a female patient has come alone, then get a female staff member to wait inside the room. And if that is an issue, then request another patient or relative to be inside the consulting room, after explaining the situation and taking permission from all concerned.

Many doctors will have a bunch of excuses. “I can’t afford to have so much staff. My consulting is small. That patient was a 70-years old lady. I am 75 years old. My child patient is only 8-years old.”

Rubbish! Just as we now all have professional indemnity insurance (just a few year ago, doctors used to laugh at the concept), and just as we now take detailed informed consent for all procedures (something that was often not done for many, many years), we need to take adequate measures to protect ourselves.

I repeat! NEVER see a female patient alone in a room! No exceptions!

And for female patients who are visiting male doctors! Please insist on someone else being in the room with you and ensure that you are never alone with a male doctor. This is in your interest as well as the doctor’s. Preferably, try and anticipate a situation like this and take someone along with you! It will save everyone a lot of trouble.

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