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I'm a radiologist and writing helps me make sense of the world. Moreover, I like to critically reflect on all things radiological. This blog is to pass on snippets of insight I have gained through these reflections

Wednesday, 4 May 2016

Renaissance Radiology

Just recently I was discussing a particularly complex case with a colleague from a nearby hospital. It was a gratifying telephone call: full of friendly banter with a wide-ranging medical conversation. Fortunately, I was able to offer help in the diagnostic chase. At the end of the conversation he laughed and said, “You really are a renaissance radiologist”.

I took this as a compliment; I think it was intended as such. Whatever his intention, it got me thinking. It is flattering to be thought of as a radiological Renaissance Man. I’m not a polymath or even anything close. But, like many others, I take pride in being a decent general radiologist with varied subspecialist interests.

However, general radiologists have a bad rap these days. Perhaps it is because, historically, mediocre radiologists simply called themselves generalists. And it is true that, statistically speaking, 50% of general radiologists are below average.

The age of sub-specialist radiology is in ascendancy. Radiology is becoming more complex; it is difficult to be good at everything. In fact, it is difficult not to sub-specialise to some degree. Furthermore, endless journal articles tell us that sub-specialists outperform generalists every time. In this age of credentialing and accreditation, you aren’t cutting it unless you have an armful of sub-specialist badges. The generalists are clearly the bumbling country bumpkins to the city-slicker sub-specialists. The message is clear: generalist, bad; sub-specialist, good.

I’ve long had a problem with this. In fact, several problems.

First and foremost, sub-specialists can be pretty useless colleagues. The more sub-specialist they are, the more useless they become. When a clinician asks for help, unless it concerns their particular body part, they hold their hands up and claim ignorance. They aren’t any good at clinical problem solving or thinking laterally. When a multi-system disorder crops up, they are all at sea.

I once met an interventional radiologist who “didn’t do CXRs anymore”. When a colleague starts down this road, the rot has truly set in. When work is being distributed, they dodge their share of the grunt work, claiming they are too specialized +/- deskilled. For similar reasons, they soon ‘have’ to stop doing general on-call and duck out of ‘duty radiologist’ sessions. Such behaviour is insidiously poisonous as it foments resentment.

Sub-specialists also tend to be either grumpy or boring. Often both. They spend years honing their skills to exclusion of all else, including abandoning all remaining social graces. When you hear of a notoriously cantankerous radiologist, it is almost guaranteed that they are highly sub-specialist. Sub-specialist radiologists are therefore like undescended testicles; hard to find and when you do find them, they don’t work properly and are often malignant.

This is even worse with groups of sub-specialists - the problem is synergistically multiplied. Pure mono-specialist groups can set new standards in irascibility; particularly in their downright rudeness to junior doctors. This is probably why radiology departments of large teaching hospitals tend to have a toxic reputation.

It isn’t just the individual radiologists. Sub-specialist radiology itself is boring. Spending hours and hours looking at endless normal scans of the same organ is skull-crunchingly dull. I can only look at 4-5 consecutive CT colons before my frontal lobes melt and drain through my cribriform plate. I look forward to my weekly ultrasound list, mainly for light relief away from a PACS station, breaking up the working week. I also look forward to on-call where at least some of the scans are abnormal.

I think this explains the career path of many radiologists. They often weave through several sub-specialties, changing every 5-10 years due to boredom. After a decade, you’ve been there, seen it all, done it all and bought the t-shirt. You need to move on.

If you meet a subspecialist who has done the same thing for 30 years, they are either an insufferable monomaniac bore or pretty rubbish at what they do. The former tends to have a degree of autism; they may be a good radiologist but people steer clear of them. The latter category has become a subspecialist in name only; they’ve never really understood it well but it is their least weak area.

I now unflinchingly describe myself as a ‘renaissance radiologist’ – I love the concept. It fuses some of the detailed skills and knowledge of a subspecialist with the breadth and flexibility of a generalist. You have great clinical utility and none of the stigma. The variety is endlessly fascinating and intellectually challenging. And if, like me, you are mid-career then you need work that continues to inspire you. At the very least this gives you a good reason to get out of bed in the morning, other than to pay the mortgage.