The Three 'Rs' Challenging Today’s Radiologists
The Three 'Rs' Challenging Today’s Radiologists
Anger, frustration, uncertainty, helplessness, and fear are commonplace emotions in the doctor’s lounge or dining room these days. We have gone from the most admired profession to what seems an endangered profession in a single generation. Radiologists, in particular, have never been well understood even by our medical colleagues.
However, there is hope. As intelligent, well-educated individuals, we have alternatives and there are definitely things that we can control that can help us create the positive, satisfying life that we all seek. From changing the way we practice our specialty to using a comprehensive, wealth management approach to plan our way to financial independence, there are things we can do. I’d like to share my perspective on the challenges and suggest some possible solutions.
I took up golf later in life. A few years ago I signed up for group lessons with a new friend. While we waited for the lesson to begin, my friend asked what a radiologist does. I explained as best I could. The part where I had to have enough knowledge to consult with specialists in every field of medicine impressed him. The kicker: Other physicians don’t consider us real doctors.
That confused him but just then we were summoned to the driving range. The instructors came down the line asking us our names and occupations. When it was my turn, the word “radiologist” had barely left my lips when the guy behind me pronounced loudly, “They aren’t real doctors, you know.” A moment later I learned his occupation: dermatologist. Ouch!
The absence of radiologists in popular TV shows such as “House” and “Grey’s Anatomy” bodes very poorly for us as a specialty. Perhaps the worst portrayal of my specialty occurred in the pilot episode of “ER.” Eric Lasalle plays a surgeon who is giving the intern, played by Noah Wylie, a tour and tells him to ignore the radiologists completely “because they are all idiots.” Okay, most doctor shows are pretty unrealistic, especially all that sex in the on-call rooms, but recently I was eating lunch in the doctors’ dining room seated at the table next to a table of orthopedic surgeons. One of them told a colleague that he should only talk to two radiologists in our group; the rest were idiots. Not only was I an idiot, I had become invisible, too. Apparently, the television scripts have a basis in reality, after all.
Another increasing trend involves our referring colleagues “throwing us under the bus.” Some referring physicians find it easier to tell a patient that the radiologist missed something or did something wrong rather than to explain the limitations we operate under or to accept any personal responsibility for a bad outcome. We have had to start adding disclaimers about everything. According to the summons, an ER doctor didn’t know that a patient could still have appendicitis with a negative CT scan. We now add the disclaimer, “A negative report does not exclude the clinical diagnosis of appendicitis.” Sorry doc, you still have to examine the patient.
Because we are rarely observed as we work — especially since we can now work remotely — the general consensus is that we never work. Medical colleagues have frequently questioned what a radiologist was doing at the hospital on weekends and after hours throughout my three decade career. Recently, as I drove into the hospital parking lot for the second round of readings on a Sunday afternoon, a visitor’s car pulled into the parking space marked with a “Reserved for the Radiologist” sign just ahead of me. In an uncharacteristic show of confidence, I rolled my window down and politely pointed out that I was the radiologist. She looked at me then looked at the sign then looked back at me and somewhat defiantly said, “I’m sorry; I didn’t know radiologists worked on weekends.” I guess we are out of sight, out of mind.
We are working harder both in terms of volume and complexity but getting less information about the patient than ever. When I began my career a large study might have 10 to 20 images; now whole body CT scans on trauma patients have close to a thousand images. Getting the reason, or as Medicare says, the “medically necessary” indication for a study has always been difficult. In the early days of hospital information systems, hospital administrators assured me that an order for a radiology study could not be entered without a valid reason for the examination. Soon it became obvious that anything could be entered into the “reason for the examination” field and the order would be accepted. “DO” became the instant favorite. At first, I thought this a cheeky, imperative command but later learned it was an abbreviation for “Doctor’s Order.” Much better.
Nowadays, we get code — ICD-9 code that is — as reasons for imaging studies. The reason for this examination is “153.9, 724.2, and 493.12.” Unfortunately, I don’t speak code; I just want a symptom or a general idea of what the referring doctor is looking for. I did learn one code, 620.2, ICD-9 speak for ovarian cyst. Since the doctor had used that exact code as the reason for the pelvic ultrasound, I felt safe, if not a little impudent, writing “620.2” on the preliminary handwritten report since the patient did, in fact, have an ovarian cyst. The physician did not find this amusing and threatened to write me up. She stated that she did not understand what it meant. Oh well, I thought it was funny.
In terms of liability, I believe things will get worse. In medical school, I attended lectures by Tinsley R. Harrison, MD, the author of Harrison’s Textbook of Internal Medicine. The eminent Dr. Harrison stated emphatically that a “test” should only be ordered to confirm the diagnosis you had reached by virtue of your thorough history and physical (H&P). Of course, only so much “testing” was possible in the 1970s. Currently, imaging, especially computed tomography (CT) seems to have become the H&P, or at least the physical. I can’t tell you how many times I have gone over the CT of a patient with the referring physician and at the end of our discussion heard, “Well, I guess I better go and see the patient now.”
One of my favorite Far Side cartoons by Gary Larsen featured two bears, one with a target on his chest and the caption, “Bummer of a birthmark, Hal.” I’m beginning to think that the symbol for radiology should be a target, not the symbol for radiation. Evidence that the widespread use of CT may be causing radiation-induced cancers is surfacing in medical publications. Unfortunately, these cancers cannot be distinguished from naturally occurring cancers, which creates a potentially huge liability for the radiologist. My crystal ball tells me that it won’t be long before we start seeing TV ads from lawyers, “Do you have cancer? Have you ever had a CAT scan? Call 1-800-BAD-RADS.”
A person can only stare at a computer screen for so many hours at a time. PACS eliminated the need to periodically stand up, stroll over to the film bin, and haul the next load of films to one’s work station. All that time spent hoisting fifty pound film jackets containing reams of films went away, as did the excellent upper body exercise it provided. It frequently took as much time for me to sort and hang a large CT case as it did to read it. Handling all those films did have a positive side. After years of hanging 14 x 17 inch films one gets the feel for the heft and balance of this tool of the trade, like a floppy throwing knife. Most radiologists of my era could toss a film into the air, impart a spin, catch the film after an exact 180-degree rotation and sail the film under the rim of the view box in one fluid motion. I suspect that was the only thing I ever did that truly impressed the surgeons.
Just like the bon bons of “I Love Lucy’s” confectionary assembly line, the RIS work list continues to self-replicate hour after hour, day after day. As a task oriented individual, I always wanted to get to the bottom of my pile before rewarding myself with a cup of coffee or a bathroom break. Now the virtual film pile seems bottomless. Studies have been done about the stresses related to reading studies from a computer monitor for hours on end without a break. Twenty-minute breaks every two hours are common recommendations. That’s great in theory but I live in the real world. I use a more physiologic measure; I get up when my backside gets numb, unless, of course, the emergency room needs a STAT CT read.