I'm so tired

 Part of a series of blogs for BJS Academy

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"I'm absolutely bloody exhausted"

These were the words of one of my 50+ yr old surgical colleagues as they slumped into a chair next to me one morning. I felt a pang of guilt: they were everything I was not. I was still perky from a double espresso enjoyed at home an hour earlier; they looked rumpled and weary. I was calm and semi-reclined in a four-point adjustable chair; they had metaphorical steam coming out of their ears. Their palpable exasperation clashed with the soft ambient noise in the reporting room; the faint hum of the air-con and the distant burble of radiologists, like monks reciting the Daily Office. 

It seems that radiology reporting rooms are a safe haven for ageing surgeons. They know that the radiology department will normally contain a known face, a sympathetic ear and an opportunity to escape the bedlam of the clinical arena for ten minutes. I’ve stopped short of offering a weighted blanket, mug of cocoa and singing soft lullabies whilst stroking their hair.

Radiologists generally welcome visits from surgeons, much more than other specialities. Many surgeons have favourite radiologists. And vice versa. But surgeons are welcomed irrespective of being known entities or strangers, young or old, charming or irascible, friendly or venomously hostile. 

This isn’t undue reverence or ego-stroking. Let me be straight - surgeons are an interruption to a radiologist’s work. We welcome surgeons simply because:

1) Clinico-radiological case discussion alters management of acutely ill surgical patients in 30% of cases. It’s an evidence-based intervention. It is also why radiologists spend about a third of their working week in meetings or prepping for them. It is also why such meetings are proliferating, ironically growing and spreading like the cancers we spend so long discussing.

2) There is an unstated reason: feedback. You need to understand that radiology is like playing golf in the dark. We launch our reports into the ether and rarely find out how they land. Occasionally there is the metaphorical sound of breaking glass but otherwise … eerie silence. We get used to it, of course, but do greedily pounce on any snippets of clinical feedback, even if it doesn’t entail being showered with rose petals and memorialised in song.

Anyway, on this particular morning, my colleague explained that they’d been on-call the previous night and hadn’t been to bed. They’d been operating and reviewing patients on the wards most of the night then attempted to do a post-take round. I was alarmed to hear that they were utterly alone; not a resident doctor in sight.  And certainly no nurse on the post-take round. Apparently nurses accompanying a ward round is a quaint memory.

This is a common theme I hear from all my surgical pals - more and more work is being shovelled onto the plate of consultants. And it isn’t just at the on-call coal face, with increasingly inexperienced and often absent residents. It is in clinic with more paperwork and less secretarial support. A friend used to see fifteen new patients in a clinic but can now only manage only ten due to a spiralling bureaucratic burden. And yet who gets blamed for clinic being inefficient? Yep, you guessed it.

Keeping on top of surgical patient-related admin seems increasingly impossible. Pooled secretaries means no one knows what is going on; the secretaries turn over faster than the residents rotate. Consultants increasingly do their own admin as they cannot rely on their secretaries. And don’t even get me started on electronic voice-recognition - it turns most consultants into very expensive typists. 

It is perhaps no wonder that am I’m starting to see burnout in surgeons; more than just physical exhaustion. Burnout is traditionally a result of work that lacks meaning, a workplace that lacks any compassion and a workload that one is not in control of. Surgery is historically the epitome of meaningful. Curing disease, alleviating symptoms and restoring function - it is doesn’t get more meaningful than that. But increasingly surgeons don’t operate, perhaps once a fortnight. Or mainly during extra lists at a weekend when theatres are free. And with modern surgical working resembling a sausage factory (e.g. pooled operating lists), it neither compassionate nor under consultant control. 

I see disappointment in surgeons of my generation. It isn’t so much at the current state of clinical practice as I think most understand the fallacy of “things were better in my day”. They weren’t better; they were always crap, just a different sort of crap. I think the disappointment is more that we feel that we were lied to. We worked like dogs for a pittance (remember 72hr weekend shifts, anyone?) on the basis that, as consultants, we’d be reasonably paid and work reasonable hours. Curious that I (and many others of my generation) have worked over 50 hours a week for the last 20 years as a consultant for way less money than my predecessors.

Perhaps it’s no wonder that UK consultants of a certain age are all cheesed off and can’t wait to retire. But the worse bit is that has happened on our watch. The progressive souring of consultant life has happened in the last twenty years. Our leaders have let it happen. We have lost much that made work enjoyable. We’ve let systems of work unravel; we’ve allowed job creep, we’ve had our altruism exploited and we’ve lost control over our workload.

I am cynically unsurprised that contract negotiations for consultants are often based solely on in-hours pay. Nothing in them about conditions. Nothing about levels of admin support. Nothing about maximum working hours. Little about out-of-hours working. Some countries are enlightened about sabbaticals and study leave but most aren’t.

It is probably too late to make systematic changes for my generation. We’ll be long out of the door. But unless working as a consultant becomes more sustainable, there won’t be a recognisable senior medical workforce in the future. The next generation won’t stand for it; they don’t believe the ‘jam tomorrow’ lies that we swallowed.

In the absence of a magical fairy godmother to solve our ills then we have to take charge of our working patterns. A big part of sustainable consultant life is looking after each other. It’s the little things; a kindly listening ear, a timely coffee, facilitating rest breaks and a chat about a tricky case. Go on; go seek out your favourite radiologist today. And if you are offering; black with no sugar, thanks.
 

Clinical Examination Is Dead

(First in a series of blog posts for BJS Academy - also available here)


I was at a national radiology conference four years ago when a consultant surgeon stood up and stated, “Clinical examination is dead”. There was a stunned silence for a few moments then hushed murmurs of discontent. She clearly believed it and stated it without embarrassment. 

I think that in the context of her talk, she meant that CT for acute abdominal pain is more accurate than clinical examination and that clinical examination has a much lesser role these days. Which is undeniable. But she said what she said.

The shock was largely that she stated very publicly what most radiologists had been thinking for years - that surgeons don’t examine patients as thoroughly as they used to. If at all. But, in fairness, I think we are kidding ourselves if examination hasn’t always been truncated in some way. 

In truth, partial clinical examination is often perfectly adequate. We don’t have the luxury of time to scrutinise vertex-to-hallux. Performing a rectal examination on every surgical patient used to be mandatory, the adage being “If you don’t put your finger in it, you put your foot in it”. Now it seems to be tantamount to assaulting the patient, such is the modern distain for using a rubber glove properly.

There is a great deal to be told from just looking at the patient from the end of the bed. Scottish surgeon Joseph Bell was duly celebrated for his visual deductions, being able to tell the occupation, recent activities and illnesses by mere observation. He was also Conan Doyle’s inspiration for Sherlock Holmes. Irrespective of observational skills, you can still diagnose peritonism by firmly kicking the end of the patient’s bed. 

There are several other cheats. You will be no doubt aware of the so-called ‘orthopaedic triple point’ overlying the lower sternal body. This is where a strategically-placed stethoscope can hear lung, heart and bowel sounds without needing to move it one inch. But who are we kidding? Orthopods don’t use stethoscopes anymore. They don’t even know which end goes in their mouth.

I was told that there is an ultimate cheat. It is possible to complete a full physical examination in less than five seconds. If a patient can hop up and down on one foot with their eyes closed whilst singing ‘God Save the King’ then you can safely say that their all body systems are probably fine. Trouble is that I’m not sure I could do that. It isn’t my Republicanism but more a question of balance.

You may agree that doing away with clinical examination seems like madness. But apocryphal sporadic tales of surgeons sending patients for scans without clapping eyes nor hands on them are now neither apocryphal nor sporadic. ‘Straight-to-test’ pathways in prostate and bowel cancer are mainstream. As is telemedicine.

Tests can completely replace clinical assessment. I heard of a story of someone who broke their leg whilst skiing in the USA. The first doctor to touch her pre-op was the anaesthetist administering her general anaesthetic for her femoral nail. Hitherto, all had been x-ray, CT, bloods and an ECG. Probably safe but horrifying nonetheless. 

Radiologists understand the frustrations of clinical examination. Examination of a patient is like a plain radiograph: specific but not sensitive. It is useful if abnormal but if normal or borderline, it is no use. That is, laying a hand on a patient’s abdomen is not as accurate as a CT but if they leap off the bed, you can be sure they will be encountering surgical steel sooner rather than later. 

Yes, clinical examination lacks sensitivity but to omit it entirely is short-sighted. There are two major problems with this approach. 

• Firstly, it makes modern surgical practice completely dependent on radiologists. It sometimes feels like that. Some surgeons, it would seem, can’t break wind without having a CT first for ‘?rectal gas’. We radiologists don’t want that; you lot don’t want that either. If every time the patient coughs, they have a CXR or CT abdo after every post-op temperature spike, the system would grind to a halt. Even more broken than it is at the minute.
• Second, radiological tests aren’t infallible. Sure, CT is better than a probing finger but it isn’t perfect. Particularly when reported by the modern breed of teleradiologist who seem curiously more fixated with covering themselves rather than giving a useful opinion. I’m astonished how even tentative reports are worshipped as gospel. Even a faint hint of a diagnosis is accepted as certain.

I don’t think we can turn back the modern tsunami of CT requests that floods every radiology department in the UK. The enthusiasm for CT amongst surgeons and ED doctors leads me to believe that they think ultra low-dose radiotherapy can heal abscesses, haematomata and even cancer itself.  Perhaps the front doors to ED should be replaced with the Hoop of Truth (aka a CT scanner)? I joke, of course. But it gets dangerously closer to the truth every time I trot out this particularly tired joke.

But can I appeal to surgeons for at least a vague attempt at the old Clinical Method? You see,  radiologists depend on a bit of clinical detail purely to estimate pre-test probability. Now I realise that most surgeons feel that Bayesian Reasoning is Devil-Speak, the sort of nonsense you’d expect from a physician. But radiologists find it useful if you say, “Nah, not really worried about this one”, so we can write off incidental blobs accordingly. However, if you say, “Paul, this patient has cancer written on their forehead”, I’m looking extra hard and not writing-off anything borderline. 

If I promise not to mention post-test probability and likelihood ratios, will you promise me to resist this straight-to-test nonsense? Will you teach your resident doctors the words of Sir Lancelot Spratt (“Eyes first and most; hands next and last, and tongue, not at all”)? You can have as many CTs as you like if a surgical hand has touched the patient’s skin beyond a simple handshake. 

Mangling of Medical English

If learning medicine is like learning a different language then learning radiology is like learning an additional related language. A bit like learning Spanish then having to learn Portuguese as well. Radiologists therefore have these three linguistic identities - normal language, medical lingo and radiology-speak. Moreover, there is verbal radiology and there is dictated radiology. And radiologists subconsciously switch between these many times a day.

When talking radiology for most of the day it is easy to forget switch modes when speaking to non-radiologists. It goes down particularly badly if you say to your spouse that, “I’ll probably get home by six, but later arrival is not excluded.” Saying punctuation marks out loud is a hazard. Humans shouldn’t say the word “Comma” out loud. Been there, done that. There is no coming back from that.

Similar to a new language, doctors learn an estimated 20000 new words, around a 30% increase. Most professions have a specific lexicon but doctors have to learn more than most. 20k words seems a little light considering for radiologists given that there are approximately 4000 named procedures, over 8000 eponyms and more than 30000 named diagnoses. It is little wonder that many radiology reports are similar to Finnegan’s Wake by James Joyce; the words are broadly familiar, the order broadly conventional but the meaning is often opaque.

For radiologists, pathologists and surgeons, there are also over 7000 terms in the international bible of anatomy, the Terminologia Anatomica. Curiously, official nomenclature omits many day-to-day terms. Take the humble acetabulum (from the Latin for ‘vinegar cup’ - I know, odd, eh?). It has one solo entry in the Terminologia Anatomica but radiologists refer commonly to the roof, the labrum, it’s columns, the fossa, both anterior and posterior margins, it’s notch and, poetically, it’s teardrop.

There are vogues, fads and fashions that come and go. You’d be looked at oddly if you started talking about a patient with bloody flux, dropsy or ague. Some of these are lovely words; I like ‘podagra’. Well, I like the word but can tell you from personal experience that the symptom is downright miserable. And, no, I don’t have saturnine gout, before you ask. But then again ‘saturnine' is a lovely prefix, invoking mysticism and Holst’s The Planet Suite.

Doctors often overcomplicate matters by introducing unnecessary jargon. I think it is mainly to make the mundane or impolite sound relatively sophisticated. Hence burping becomes eructation, a nosebleed becomes epistaxis, goosebumps becomes horripilation. I find it occasionally amusing but fundamentally impedes communication. Excessive jargon is enough to induce spasm in the Levator Labii Superioris Alaque Nasi, mydriasis, diaphoresis and trichotillomania.

I don’t know if this happens in other languages but medics often abuse English adjectives. The severity or type of symptoms are often described with bizarre descriptions. For example haemoptysis can be oddly ‘frank’, psychosis is somehow ’florid’ and tenderness is ‘exquisite’. Quite why these adjectives are thought appropriate, I don’t know. They certainly don’t translate - frank tenderness, exquisite psychosis and florid haemoptysis sound plain odd.

Other phrases are odd too, when you stop and think. We talk of ‘deranged’ liver function tests whereas it’s normally a word reserved for an extreme mental state. We talk of lesions as being ‘aggressive’ as if they were sentient and deliberately chosen a path of violence. We talk of ‘fulminant’ conditions but this word actually derives from the Latin for ‘striking with lightning’. And I’ve never understood allocating human emotions or conditions to symptoms or diseases. ‘Respiratory embarrassment’ and ‘cervical incompetence’ both sound like their respective organs should be blushing.

Speaking of the cervix, some medical phrases are need to be changed as they are rooted in attitudes that are no longer appropriate. We’ve got rid of eponyms and textbooks named after war criminals, which is a start. But several terms, for example, in gynaecology are felt to be rooted in misogyny. ‘Blighted ovum’ isn’t exactly a pleasant phrase for someone desperate to conceive. Anembryonic pregnancy or empty sac are both better.

Radiologists have a tendency to mangle medical English like no others. We call lesions ‘suspicious’ or ‘worrisome’, ascribing our emotions onto them as nouns. Ok, if we are doing that, why can’t extend to label diseases with a wider range of emotions other than doubt or concern? Could a large central pulmonary embolus be described as ‘panicky’? Or a renal tumour with a volume doubling time of ten years be labelled as ‘boring’?

There are still many radiologists who are afraid of the word ‘normal’. At last count, there were twenty eight different English euphemisms for this simple word. I neither have the time, space nor energy to have that debate right now but these euphemisms should be used sparingly. Imagine you are describing a face, genitalia or some sexual characteristics. If I, for example, had breasts, would I be happy with them being labelled ‘unremarkable’ by a radiologist? Or if my nether parts were described as ‘normal for age’, would I take offence? I prefer superlatives when talking to patients. They never fail to smile on being told that their pancreas is ‘really quite beautiful’.

The English language evolves and so should I, apparently. But, dear reader, I’m not quite as tolerant as I should be. There are a few neologisms in medical English that grind my gears. It is a modern trend to deviate from long-established descriptions such as dyspnoea, breathlessness, hypoxia as something else. I can tolerate SOB (short of breath, not the other one). I’m happy with ‘low sats’. But I cannot tolerate ‘new oxygen requirement’. Do we describe thirst as ‘new fluid requirement? Or tiredness as ‘new sleep requirement’? Or infection as ‘new antibiotic requirement? No, we don’t.

I realise that I am increasingly a middle aged man shouting at clouds but I was always taught acronyms should be avoided in medical notes. There are known clinical risks to using them. I remember this as AAA - Always Avoid Acronyms. Anyway, there are some new ones on radiology requests that baffled me.

• BIBA = ‘brought in by ambulance’. which whilst interesting, the mode of patient transport has no relevance to me as a diagnostic radiologist.
• NEWSing = an awful neologism, where an acronym is treated as a verb. It basically describes someone deteriorating clinically (their National Early Warning Score has gone up, generally over three) but is totally non-specific and therefore useless to a radiologist. It is like writing “Ill ?cause”.
• HFpEF = Heart Failure Preserved Ejection Fraction. Apparently a useful way to think about causes of heart failure but can’t help thinking that classifying a disease based on a normal test result is downright odd. Are we going to see LRTIpCXR (Chest infection; normal chest radiograph) or C?CnCTH (confusion of unknown cause but normal CT Head)?

I should stop now otherwise I’ll be giving them ideas. But the principle still stands that doctors need to be kept in check otherwise they invent increasingly bizarre language. And we radiologists should check our own practice: employing simplicity of phrase; eschewing arcane jargon and ensuring our reports are not Joycean. An unreadable report will remain unread. And an unread report is the most dangerous sort of report

Of Diphthongs and Digraphs

Until recently I had no real idea what a diphthong was; I had the vague notion it was some form of sprocket or perhaps part of an internal combustion engine. You see, Dear Reader, I didn’t have a classical education. When I was at school ‘Grammar’ was what we called my mother’s mother. I’m therefore a self-taught writer, almost entirely lacking any technical knowledge of English literature. Writing in the vernacular is all I have. But it worked for Hemingway and Vonnegut so it is good enough for me.

Anyway, my knowledge of grammatical arcana got a upgrade recently. When looking up the correct medical spelling of ‘fetus/foetus’, I spent a happy hour or two down a rather deep internet rabbit hole, bouncing around related topics, completely divorced from reality. As it turns out, there is an accepted spelling of the term in British medical practice. And that is ‘fetus’.

As I was brought up spelling it ‘foetus’, this was a minor shock. Unbeknownst to this adult radiologist, it has officially been ‘fetus’ for over a decade not just on this side of the Atlantic but globally so. Our American cousins may celebrate this as a win, thinking the Brits have come to their senses and started using the simpler American spelling. But it isn’t quite the win they might think it is.

It is simply that fetus is closest to the original Latin word fētus (meaning breeding or birth). But why did foetus ever arise in the first place? Therein lies the entrance to the aforementioned rabbit hole. You see, during the 16th Century, a whole language of English medical words derived Latin and Greek came into use to describe new medical discoveries. It wasn’t an intellectual flex just that they were the scholastic languages of the time. As a result, a large number of words were introduced that were supposed to retain some of the grammatical features of its source.

Except translators often hypercorrected matters, introducing prestigeful spelling based on etymological fallacies. Which led to multiple different spellings of fetus, foetus, phoetus and fætus before finally agreeing on foetus. Except they settled on the wrong spelling. The original Latin fētus was pronounced with a long ‘e’, denoted by the little line above the letter (called a ‘macron’). So fetus should really have been spelled ‘feetus’ if we are going to utterly logical about it. But it is a bit late for that now.

The ‘oe’ bit in the middle of foetus is supposed to be, I learnt, a diphthong. This is where two letters create a syllable that glides across the mouth. The exclamation “Ah!” is a monophthong whereas “Ow!” is a diphthong. Perhaps the original thinking was, presumably, that ‘foetus’ should have been pronounced ‘foe-ee-tus’. Whereas it was always pronounced ‘fee-tus’. So the diphthong argument for the ‘oe’ in foetus doesn’t stand up.

More: the ‘oe’ bit is also a digraph. This is where two letter combine to form a sound, potentially unrelated to the spelling. The digraph ‘oe’ usually denotes a long flat ‘o’ such as in ‘toe’ or ‘poet’. Fetus was never pronounced ‘fow-tus’, so justifying foetus as a digraph doesn’t hold water either. The same is true with the words ‘fetor’ and ‘fetid’, from the Latin fētor, meaning ‘stinking’. We Brits should have never used ‘foetor’ or ‘foetid’ and it has been largely dropped. Feetor, anyone?

I began to wonder about all the other different spellings between British and American medical English. Were haematology/hematology; hydrocoele/hydrocele, tumour/tumor all originally misspelled by scientists of the Enlightenment? Well, no, as it turned out. It is more complex than just dropping redundant diphthongs and ignoring etymology.

Many American English medical spellings are along the principles set forth by US lexicographer Noah Webster. Webster’s 1828 American Dictionary of the English Language was trying not just to simplify spelling but also to unify spelling across the then fledgling USA. However, many modern medical words (like ‘paediatrics/pediatrics’) were coined well after Webster’s time. We Brits can’t point the finger directly at the Webster on this one. Nor can we blame the Merriam brothers who bought the rights to Webster’s work after his death.

I’ve read many arguments that British medical spelling is more accurate because it reflects the etymology of the word. Hence ‘oesophagus’ should retain it’s initial ‘o’ because the original Greek word was οἰσοφάγος or oisophagos. But we don’t call Egypt ‘Aegypt’ just because the Greeks and Romans spelled it with an ‘A’. I’ve also read that we should retain the digraphs ‘oe’ and ‘ae’ as they are pronounced subtly differently to ‘e’. Well, that might once have been true but not now.

Does it really matter about there being one ultimately correct medical spelling of the word denoting the unborn child or gullet? Not really. I feel lucky that English is the lingua franca of medicine. As a Brit, I can go to international conferences and everything is in my birth tongue. But as a global language, English is ever evolving and will keep evolving. Local variations of English exist in multiple dialects across the world. But the spoken word and the written word evolve at different speeds. The written word lags behind by some distance. Several hundred years in many cases.

Aside from my new love of all thing fetus, I’m largely averse to changing the spelling of British English medical terms. We’ve never had the equivalent of Académie Française, a 400 year old French institution solely dedicated to regulating French grammar, spelling and literature. English has a 1600 year history from it’s roots as a West German language from Anglo-Saxon invaders. It then absorbed many words from others, largely Norse and French invaders. This mish-mash of odd words give a richness and depth but it’s loose grammar structure allows flexibility and ease of use. It’s too late to change spelling of words wholesale; moreover we don’t want to. We like it as it is. Albeit a tad messy.

So what if we now pronounce many words quite differently from their spelling? So what if they are hard to spell and confusing for non-native speakers? All languages have oddities that way. But if my American cousins want to spell things differently, you guys go for it. Knock yourselves out. Whatever works for you. Just don’t expect us to change. Or agree that one way is somehow ‘better’.

Because if we start changing the spelling of British English words to match modern global pronunciation, we’d be absolutely screwed. For example, the sentence “Worcester knight Colonel Geoff sliced the tough sugar cake using a sword” makes complete sense to Brits. But if you change it to ‘Wuster nite Kernel Jeff slysed thu tuff shugar cayk yoosing ay sord’ it makes phonetically sense but it becomes absolute gobbledygook.

My overall thoughts? Ignore the grammar pedants, ignore the nationalists, ignore international standardisation committees. Minor spelling and grammatical differences cause no harm. I say leave things be and just celebrate our differences. Let language evolve naturally. Don’t fight with dialects or correctness of spelling. It comes across as sneering cultural snobbery. No snobbery is good but that is definitely the worst sort.

Fred Astaire and Ginger Rogers had it right in 1937 when they sang “potato, potahto; tomato, tomahto, let’s call the whole thing off!” We need each other too much to squabble over words; we can be happy and work together productively, spelling notwithstanding.