From a series of columns for BJS Academy
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This summer has been difficult for me. A very good friend died in June. My pal, Barry Kelly, was a Belfast-based radiologist who originally trained as a surgeon in Glasgow. Kind and supportive, he was a brilliant wit and raconteur; everyone’s favourite colleague. He was also a polymath who seamlessly wove together literature, philosophy, history and science: very much the Stephen Fry of radiology.
A few years ago, Barry introduced me to the concept of Plato’s Cave. In this allegory, ancient Greek philosopher Plato imagined a group of people who spent their lives chained to the wall of a cave, facing the blank back wall. The prisoners could not see anything else apart from shadows projected on the back wall of the cave, made by people passing behind them and by the objects they carried. The shadows and the cave are the complete reality of the prisoners, as they knew no different.
Plato was illustrating that our world view is formed by observation and that observations are intrinsically constrained by one’s viewpoint. My cultural muse, Professor Kelly, made the point that this is an excellent metaphor for radiology. The images that a radiologist looks at are shadows of real patients but only a partial reality. Radiology departments could be thought of as modern Platonian Caves, where radiologists sit in the dark, gazing at flickering shadows on PACS monitors. Hopefully not while chained up though.
The radiology-shadow metaphor is not new. In 1963, Harvard radiologist Harry Mellins used it to set out the case for radiology being given equal status to bedside medicine:
“The radiologist perceives the shadow, sees a lesion, and imagines the patient. The bedside physician sees the patient, perceives the signs and imagines the lesion. They practice from outside in and we from inside out…This, then, is the concept of the radiologist - a film on the light box, but the bedside on their mind”
Mellin’s notion that the radiological shadow was a partial but nevertheless equally valid picture of the patient. Crucially, this view is complementary to the external views afforded to a surgeon, building up more complete picture of the patient.
Being able to see a disease changes how we think about it. There are some diseases that are not detectable by touch, vision, smell, sound or, God forbid, taste. Nor can they be detected any of the other nine, ten, twenty-one, thirty-three or fifty-three senses (depending on your definition of what a sense is). Such diseases remain abstract, revealed only by symptoms and, say, blood test anomalies.
Seeing disease on modern radiological images is a radical change from yesteryear. I grew up understanding disease through conceptual diagrams, pink blobs on microscope slides and pickled specimens in jars. Radiological visual understanding of disease is increasingly true where many surgical conditions are managed non-operatively and even then increasingly only seen via the fisheye-lens of a laparoscope or endoscope.
Hence surgeons often find their pet radiologist to go through scans so as to understand the patient’s disease. Except it can be hard to spare the time and find the right sort of radiologist. As a rough rule, the more often a surgeon is found wandering around a radiology department, the more it is a good idea to have a regular X-ray meeting. A meeting is much more efficient than ad-hoc scan reviews.
X-ray meetings can be thought of as viewing both sides of the same coin. The radiological shadows are the heads, the clinical view is the tails. There is some evidence that this holistic view improves disease management. One study showed that a morning GastroIntestinal X-ray meeting reviewing acute admissions from the previous 24hrs changed patient care in 30% of cases reviewed. Some of this is scan reinterpretation in light of new clinical history or getting a second opinion. But a lot of it is getting expert surgeons and expert radiologists in the same room.
Modern surgical practice is complex and X-ray meetings can help with decision paralysis. X-ray meetings are also increasingly necessary to review the massively increasing number of scans surgeons need to act on. Not just scans they’ve asked for but scans of patients they’ve been asked to give an opinion on.
Consequently, there has been a significant rise in the size and number of Surgical X-ray Meetings. It isn’t just surgeons, everyone wants their own x-ray meeting nowadays. At any one time in any one hospital there are multiple x-ray meetings happening simultaneously. The hospital I work in has sixty-three different X-ray Meetings, 2/3rds of which are weekly or daily meetings.
This has roughly doubled in the last decade, with growth in everything from informal X-ray meetings to formal site-specific oncology multidisciplinary team (MDT) meetings. Not only have the meetings increased in size but also in the number of patients discussed. It is not uncommon to have over 100 patients listed for MDT discussion in a three hour meeting. And often no one present has actually met the patient.
At less than two minutes per patient, we are kidding ourselves that any significant discussion happens in 95%+ of patients. The end result is that the all the holistic benefits that Mellins envisaged are all diluted to homeopathic proportions. The beautiful union of radiological demonstration of disease and bedside surgical assessment is lost.
Such big meetings are dysfunctional; they paradoxically fail to change patient care. They are also expensive in terms of staff time. One working estimate is £100 per patient. So a big MDT is £10k. My hospital is therefor easily spending £100k a week on MDTs every week. Many consider big MDTs to be highly cost ineffective; a luxury the NHS cannot afford.
Urgent action is required: bold action is required. I like an x-ray meeting but big MDT meetings generally advance patient care not one jot. You could scrap the whole edifice and replace it with protocol-driven care and smaller meetings for complex patients, where case discussion leads to meaningful advances in their care.
Plus if you scrapped big MDTs, nearly 5000 consultant radiologists across the UK would simultaneously leap for joy. And we’d be able to get on with some actual reporting for once.
