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I'm a radiologist and writing helps me make sense of the world.

"My method is to take the utmost trouble to find the right thing to say, and then to say it with the utmost levity" -George Bernard Shaw

Sunday 10 February 2013

The Rules of Radiology


These are simple rules of radiology; uber-truths, the very essence of our dear speciality.

Rule #1 / / Obey the Rules
Your reason is to knowingly breach The Rules isn’t good enough. It never will be. It is also forbidden for someone familiar with The Rules to knowingly assist another person to breach them.

Rule #2 / / Smile
Those who complain the most, accomplish the least. And remember, nobody likes a whinger.

Rule # 3 / / Keep your cool
Losing your temper always makes things worse. Anger reveals weakness of character. Equanimity is hard but worth it.

Rule #4 / / Work hard
It is the radiological trump card, “Yes he may be a sociopath with BO that makes paint peel but he works hard.” But don’t work too hard. You only have a finite time on this planet

Rule #5 / / Toughen Up
Modern medical practice is tough. Patients still die despite all best efforts. Other doctors aren’t always nice to each other. No one said it would be easy. Develop a thick hide, become stoical and just get on with it. See Rules #2 and #3

Rule #6 / / Respect the machines
Don’t verbally abuse the scanner or let it know you are in a hurry. They have sensors for that and will shut down. They are particularly sensitive after 4.50pm, Friday afternoons, on the birthdays of loved ones and on anniversaries.

Rule #7 / / Never let a clinician play radiologist
If the request gives specific radiological directions, you must do the opposite. A request for ‘CT with contrast’ means they get an unenhanced scan; any request for “obliques” gets just an AP and lateral.

Rule #8 / / Forgive the sins of the clinician
They are just jealous. There are two types of doctors: radiologists, and those who wish they were radiologists. After all, we have the most expensive toys and the comfiest chairs.

Rule #9 / / Don’t be too approachable
You don’t want to be the one who gets asked to do everything anymore than you want to be the one that everyone slags off as being grumpy and lazy.

Rule #10 / / Be a good colleague
A good radiology department is where you show cases to each other on a daily basis. Experienced colleagues get their egos checked; younger colleagues get a helping hand. If you aren’t doing this, you might be part of the problem.

Rule #11 / / Never measure anything
A radiologist with a ruler is a radiologist in trouble. If you can’t measure it with the eyeball-ometer, you are out of your depth. Accurate measurements honestly don’t matter. The nearest centimetre or so is absolutely fine.

Rule #12 / / Never count anything
If you are trying to equate quality or experience with activity, you are missing the point. You could be doing the wrong thing over and over again. Anyone who brays about their ‘numbers’ is indeed an ass. If counting is the sole rationale, you are the wrong person to be doing it.

Rule #13 / / The default is to say ‘yes’
There are 2 sorts of radiology requests; requests from a competent and knowledgeable colleague, which you accept; requests from an incompetent and bumbling colleague, which you accept right now. Saying ‘no’ always involves more work in the long run.

Rule #14 / / Agitation is not an indication
Lack of planning on their part does not constitute an emergency on yours. Let them get away with it and they don’t learn the lesson.

Rule #15 / / Always help the patient
Helping the medical team is helping the patient. The natural tendency is, of course, to say yes (see Rule #13). Apply the ‘grandma test” – what if it was your grandma? Sometimes helping means saying no – it might not be in the patient’s best interests (see Rule #16)

Rule #16 / / Be damned careful when saying an outright ‘no’
The hardest part about being a radiologist is knowing when not to do something, when to say no. The clinician has seen the patient, you haven’t. But if the most appropriate clinician hasn’t seen the patient, feel free to say no. See Rules #13 & 15.

Rule #17 / / Don’t study surrogates
Many radiologists spend hours studying, with great precision, that which does not matter. Cut to the chase; study important primary outcomes, irrespective of how hard it. Anything else is lazy.

Rule #18 / / Avoid ‘interesting’ cases
They aren’t. They’ve asked everyone else already. And, no, they don’t have a clue either.

Rule #19 / / Beware the ‘fit 90 year old’
There is no such thing.

Rule #20 / / Counteract misjudgement
Staff and patients make snap judgements about you. Overcompensate. Dress smarter and behave more professionally than you think you should.

Rule #21 / / There is no such thing as a radiological emergency
If the patient has a cardiac arrest in the department it isn’t strictly a radiological matter. Whilst it is polite to show an interest, they’d be honestly better off with the crash team. Otherwise, you should always finish your cuppa before the next task. Rushing things causes errors. Stay calm, stay safe.

Rule #22 / / If you feel resistance, stop pushing
This is the cardinal rule of interventional radiology. Same rule applies when cleaning one’s external auditory meatus.

Rule #22 / / Use words carefully.
Clarity of communication is everything. A good test is ruined by a poor report. Never, ever write, “Clinical correlation advised”. Ever.

Rule #23 / / Brevity is king
The longer the report, the greater the uncertainty. Also, clinicians won’t read it; anything longer than 4 lines and they skip to the conclusion.

Rule #24 / / Question everything
Dogma has no role in radiology. If you never doubt yourself, you are wrong a lot.

Rule #25 / / Ditch the stethoscope
Who are you trying to kid? You don’t even know which one is ‘lub’ and which one is ‘dub’ anymore. Oh, and lose the bow tie. Seriously. It makes you look like a pillock.

Rule #26 / / CT is easy
Real hardcore radiologists do loads and loads of plain radiographs (NB they are not counting - see Rule #12). They do them quickly but take pride only in their accuracy. Anyone who ‘doesn’t do plain films anymore’ is a work-shy fop.

Rule #27 / / Don’t answer the phone
It is not for you. The more you answer the phone, the more it rings. Even if it is for you, it isn’t a social call. Ignoring it encourages face-to-face consultations. These are better for clinical care and certainly a lot more fun for the radiologist.

Rule #28 / / Stay safe the easy way
In a high-risk patient, the lowest rate of complications occurs when you don’t meddle. Contrast nephropathy is unheard of if you don’t give contrast. Patients don’t exsanguinate from a biopsy that didn’t happen.

Rule #29 / / Get off the fence
Do not let the fear of being wrong rob you of the joy of being right. If you absolutely have to equivocate, you are only allowed one hedge per sentence, “There appears to be a possible nodule” tells much, yet almost nothing.

Rule #30 / / Don’t pick fights
Arguing with clinicians is like wrestling with a pig in mud…after a while you realize the pig likes it. See Rules #3 and #38.

Rule #31 / / Beware the ‘good’ case
The impressive case that you think you’ve nailed and thus triumphantly show to all and sundry is only a biopsy away from being a classic mistake.

Rule #32 / / Don't fret about complications
If you haven’t encountered complications during a procedure, you haven’t done enough of them. They will still happen irrespective of preparation, training, skill, carefulness and clinical likelihood. The complications you worry about don’t happen and the ones that do are unforeseeable. See Rule #5.

Rule #33 / / We are not the business of exclusion
No test is 100% sensitive. We don’t do ‘rule outs’. Ever.

Rule #34 / / Trust your clinical instincts
Take a brief history and tailor the examination appropriately – the patient is trying to tell you their diagnosis. However, if your barium enema patient starts Cheyne-Stokes breathing just as you are seeing the caecum properly, you should probably stop.

Rule #35 / / If you have to fail, fail safely
Struggling is learning. But only to the point that adrenaline turns brown. Recognize your boundaries and approach them cautiously, with the cavalry in the wings.

Rule #36 / / Take clinical details with a pinch of salt
We were all junior doctors; we know why they write the clinical details that they do.  We understand that clinical examination is fickle - the words ‘shifting dullness’ are 100% negatively predictive for ascites on ultrasound. We understand the pressures - ‘?SDH’ on a CT Head card merely means the boss’s ward round is looming. See Rule #37.

Rule #37 / / Don’t crap on juniors
You can judge a doctor by how they treat those lower on the medical ladder. Those on the lower rungs need a hand up. A radiologist can provide help and education. Education, however, can be delivered pretty assertively. Especially at 3am. See Rules #2, #3, #9 and #36.

Rule #38 / / Aggressive clinicians need your help
If a doctor gets rude and shouty, they are usually (i) out of their depth, (ii) unsupported and (iii) worried about their patient. See past the emotion and try to help. Persistent offenders need showing the door and reminding, “My scanner, not your scanner”. See Rule #3.

Rule #39 / / Know loads
The job of the radiologist is to explain every pixel. Not just hazard a guess, but to know categorically. If you can’t explain something, you aren’t as good as you thought you were. See Rule #4.

Rule #40 / / Never offer to eat your pants
You might be so totally convinced in your diagnostic accuracy that you offer to do something silly if you are wrong. Sure as eggs are eggs, you will be tasting cloth sooner than you think.


  1. Coobs, a slice of fried comic gold. Yours, boot.

    1. Dearest Boot

      You are most kind - deep fried precious metals, mmmm! Like the Ignobel Awards, the plan is to first and foremost make you laugh then, perhaps, make you think.

  2. enjoyed your post, loads!

  3. I stumbled across your blog when i googled you after agreeing vociferously with a comment you made on 'The future of radiology - a discussion paper' on the RCR website.
    This post made me laugh out loud so many times and I have now circulated it amongst my colleagues as several of the rules are appropriate to them down to a tee!!!!
    Thank you for taking the time to write this and making a boring interview revision session less so!

    1. The fact that you agree with me 'vociferously' on something means we are now BFFs. Stick with me and you'll get on fine.

    2. Hi, I also agree with you ;-)
      what BFFs mean?

    3. I understand (from my children) it is "Best Friends Forever". *clears throat nervously*

    4. Or best female friend... ;)

  4. This is a good post. Enjoyed it, thanks for sharing.

  5. This is the best radiology column I've ever read. Congratulations, I will post it on my door!

  6. Very nicely done. Funny yet realistic

  7. very well written. quite educative.
    safe,slow and study wins the race.
    Dr MK Goyal,MD,MD,DHA

    1. Thanks. But what is this 'quite' business? I think you meant to write 'highly' ;-)

  8. Universal truths for radiologists, even many clinicians like most of them. Thanks for sharing. A Spanish translation available here:

    1. Julio - you are my Spanish Radiology Hero. Truly.

  9. Hello! Thanks for posting the Rules.
    I m having a trouble with understanding sociopath with BO. What does "BO" stand for?

  10. Hi Paul, I thoroughly enjoyed reading through the rules. I am gonna share it with all our new radiology trainees with your permission.

  11. Martin:
    Hello, thanks for this radiologic points, i agree with most of them:-), i will post it to my facebook group of young czech radiologists if it is no problem...Martin

    1. No problem Martin, feel free. But remember, agreeing with '...most of them...' is not an option: it is all or nothing! See Rule#1

  12. Hi Dr...i sincerely appreciate your efforts in writing these rules for radiologist...and i liked it from my bottom of heart...definitely i am going to share it with Indian radiologist pals ..off course with your permission...thank you once again.

    Dr. Digvijay. radiologybits.blogspot.in

  13. even many clinicians like most of them. Thanks for sharing

  14. Hi Paul,

    Love this list. I just might frame this and display this in my office. I see that your wit is as sharp as it was more than a decade ago, and if anything it has become more refined and sharper with time! Keep these pearls of wisdom coming!!

  15. Thank you for sharing such wonderful information!In my opinion, Keep a healthy life by consuming healthy food and doing exercise regularly is the best diet formula.

  16. This is so true and so funny! I've read this many times before becoming a radiologist, and sitting today in my office, finally a radiologist (in sunny Cyprus!), it came to mind and I read it again. Made my day. Thank you :-)

  17. strangely relevant to radiologists in every part of the wirld :)

  18. Measurements matter, unfortunately. Nearest centimeter won't cut it with growth of small intracranial mets, etc. Pretty sure you are not a neuroradiologist.

    1. I'm not saying measurements don't matter. Highly accurate measures are, in fact, (i) impossible to perform reliably (ii) not actually necessary in the majority of cases and (iii) often unnecessarily and crudely reductionist.

      I measure mets day in, day out. I look first and measure later. But I do so in the knowledge that precision is a myth. Even the cleverest radiologist since the earth cooled will struggle to manage accuracy to give or take 10% accuracy.

      Ironically, the only thing where a few mm truly matters is kidney stones.

  19. 2021, and after 08 years, your rules still make me think and laugh. Will try to follow Rule 27, although it is hard in these Whatsapp days.

  20. the best ever radiology columns from one of the best radiologists