More Rules of Radiology

Another 20-odd Über-truths, to be read in conjunction with The Rules of Radiology. Remember Rule #1 : You must obey the rules...

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Rule #41 / / Radiologists don't wear suede shoes

Or brogues, open toed shoes or sandals. You'll know why once you grasp the concept of secondhand barium.

Rule #42 / / Never investigate on the day of discharge

Such tests always turn up something unexpected. It'll prove ultimately benign but will take a week to sort out.

Rule #43 / / Only give clinicians 15 seconds

If they can't cut to the chase, help them. We haven't got all day. The longer the preamble, the lower the pre-test probability.

Rule #44 / / You can never know too much anatomy

The more anatomy you know, the better the radiologist you become. It's the only thing you learn at medical school that won't have changed by the time you retire.

Rule #45 / / Be careful with "limited" or "quick" studies

Guaranteed you'll miss the cancer. Better off doing the full Monty or nothing at all.

Rule #46 / / Image quality is up to the radiologist

Image noise, coverage, adequacy of position and so on are all dictated by what you are willing accept, not by what was produced.

Rule #47 / / It is never a chordoma

Rare presentation of a common disease is commoner than common presentation of a rare disease. That classical rare bone lesion will turn out to be just another bone met.

Rule #48 / / Reporting rooms should be pitch black

If you report with the lights on, you are letting the entire profession down. Reporting in a dark room is for logical visual reasons but it also handily disorientates those who trespass.

Rule #49 / / Don't touch the screens

Not with greasy fingers, never ever with pens. The dirtier the screen you'll tolerate, the sloppier a radiologist you are.

Rule #50 / / Error is inherent to radiology

Get used to it. The images are subjective. Every cancer starts really, really small. The human body is really, really complex. See Rule #51.

Rule #51 / / Savour mistakes

And near misses too. Even the best radiologists can make the worst mistakes - you cannot know it all. But everyone can learn.  See Rules #38 and #50

Rule #52 / / Don't rush a report

Clinicians bizarrely expect it instantly. The more complex the scan, the sicker the patient, the closer they crowd you. Dispel them with 'You can have the wrong report now or the correct report in 15 minutes'

Rule #53 / / Never wake a patient up

If they are sound asleep, they don't need a scan right now. Sleep is good for ill people. However, probably wise to double check they are actually asleep and not moribund.

Rule #54 / / Know about esoterica

If you hear hoof beats and see stripes, it could be a zebra. There are so many rare conditions that it is common to have at least one of them in the hospital. See Rule #39.

Rule #55 / / Doctors aren't porters

If you let them just 'drop off a form' and leave without another word then you are doing them, you and the patient a disservice.

Rule #56 / / Don't shoot the messenger

It isn't the poor newbie medical houseman's fault that the 'surgeons want a CT before they see the patient'. Instead of ripping them a new orifice, save your ire for the original miscreant. See Rules #36 and #37

Rule #57 / / Question 'protocols'

If the major reason for a scan is due to 'the protocol', ask to see it 'for my education'. The protocol in question usually either doesn't exist or states exactly the contrary.

Rule #58 / / Don't be a hairdresser

Hairdressers never say 'you don't need a hair cut'. Question the motives of those who are paid per scan, especially when they recommend expensive additional studies.

Rule #59 / / Prognostication is not an indication

If someone is so ill that they are not fit for a haircut then a scan isn't going to change anything. It is wasting everyone's time. See Rules #15 and #64.

Rule #60 / / Beware of Mr Twitchy

If a patient can't stay still, abandon it straight away. Get them back another time. Otherwise you get asked to interpret a twitchogram. And that never ends well.

Rule #61 / / Always look at the scout image or localisers

That 10cm RCC isn't on the sag T2. And that basal lung cancer isn't on the volume dataset. Ignore them at your medico-legal peril.

Rule #62 / / Dictate considerately

If a secretary 6 rooms away can clearly transcribe your every word, you should probably speak a little more quietly. You are also probably irritating your colleagues beyond belief.

Rule #63 / / Don't scan instead of talking

Resist pressure to omit clinical discussion. Talking is cheap, quick and can avoid scans altogether. It also has relatively few serious side effects.

Rule #64 / / Never scan the dying

It is highly distressing, undignified and tantamount to assault. No amount of diagnostic electromagnetic waves will stop Mother Nature. See Rule #59.

Rule #65 / / Don't be a smart arse

Scans often only become a waste of time after you've done them. It's easy to be wise with hindsight: only a facile radiologist does this.

Rule #66 / / False positives are errors too

Over-calling is as equal a sin to under-calling. If you can’t report a CXR without asking for a CT, you need to take a long hard look at yourself. See Rules #29, #50 and #51.

Rule #67 / / Vetting requests is worthwhile

If you let other people do it for you (or don't do it at all), you cannot complain about unjustified scans or scrambled clinical reasoning. Man up and JFDI.

Rule #68 / / Be a holistic radiologist
Look at the whole image not just your area of interest. You may be the cleverest spinal radiologist since the Earth cooled but missing a 7cm AAA on MRI L-spine is never clever .

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Read Even More Rules of Radiology or The Rules of Radiology Book

How to be a famous radiologist

You may think, ‘Who is he kidding? There is no such thing’, and to a certain degree, you’d be right. Radiologists are rarely frontline macho types. In the grand scheme of most hospitals we are bottom of the heap, just above the pathologists. Even the hospital cockroaches will get their own personal parking space before we do.

Even the great and good of radiology have rarely broken through the surface tension of public consciousness. In medical circles, Sir Peter Kerley got his B-lines remembered but his A and C lines have sunk into obscurity. Henry Pancoast has an eponymous apical lung tumour in his honour but out of an estimated 8000 eponyms, he is a pretty lonely radiological name. No radiologist has won a Nobel prize but our own local-lad-done-good, Dr Brian Witcombe, won the Ig Nobel prize in 2007 for his pioneering work on the radiology of sword swallowing.

You might also think, “What right-minded radiologist wants fame?”. Surely we all chose radiology because we don’t have mile-wide egos. We are happy in our role; we don’t need to be praised or loved, we know we are in the best speciality. Although I’ve met some right prima donnas I can’t imagine a ‘rockstar’ radiologist, reporting whilst wearing cool shades and tight leather trousers. However, i suspect every radiologist would like to contribute something of worth to humanity or to be fondly thought of for their achievements.

Strictly optional for a radiologist

Even if you wanted to be famous, it is increasingly difficult. 20-odd years ago, the average hospital proudly sported 5 or 6 radiologists. Now most places have that many just specialising in MRI of the left nostril. As one individual of many, you are just a small cog in a much bigger machine. No matter how much heat, noise and light you create, you are just a voxel in a low resolution matrix.

It isn’t nice to hear, but we are dispensable. Departments now run happily without you. Sometimes this is deliberate. A famous radiologist was once asked ‘You are so terribly important and busy, who does the work when you aren't there?’ to which he responded, ‘Exactly the same people as when I am here’.

I know of very few genuinely ambitious radiologists. They are often worthy individuals who achieve much through hard work, long hours and exploitation of every ounce of their talent. Although many of them cannot remember the names of their children, are on their 3rd or 4th marriage by the age of 50 and tend to keel over from a heart attack shortly thereafter. 

Furthermore, ambition is never far from avarice or narcissism. No one likes the thankfully rare individuals that self-aggrandise; their hubris is noxious. They want power, status and money that is out of keeping with their abilities and achievements. They may achieve brief infamy but soon fade from view as they disappear up their own backside.

Most of those in official positions of power are there because they didn’t step back quickly enough when volunteers were asked for. Their time in the limelight is spent blinking, smiling nervously with an unmistakable glint of terror in their eyes.

Many of us spend a lot of time managing our departments. It is a crucial task to keep the clinical service running smoothly. But does anyone remember who led a business case to install a particular scanner? The only people guaranteed to read departmental protocols and policies are the people that write them.

Let's distinguish between managers and leaders. Managers are functional administrators, keeping the ship seaworthy. Leaders are at the helm, steering through choppy waters, unconcerned with a little water lapping over the edge. No one remembers those whose primary concern was stopping the boat from rocking. Bold leaders are remembered. But it is a rare individual that feels comfortable steering a huge rickety vessel down treacherous rapids.

Academic fame is near impossible now. The low hanging fruit of research have been picked. The days are long gone where a seminal paper could be achieved in a single afternoon with only a bottle of contrast, a long needle and a nervous-looking student volunteer. The profusion of radiology journals now means that any academic achievement is instantly diluted to homeopathic levels.

However, everyone always remembers a good teacher. They inspire and edify countless individuals over the years. It is easy to achieve: offer to teach and you are pushing at an open door. But I must say that the whole thing about “He who can, does. He who cannot, teaches” is utter rubbish. I’ve only had great teaching from great radiologists. Admittedly, we can’t all be great but if you do it with enthusiasm and a smile, you are half way there. The best bit is that teaching is a valid reason for taking a break from the daily grind. And after a decade or two of ploughing the same field, reporting Sisyphean piles of radiographs of mildly osteoarthritic joints, you most definitely need regular breaks. 

Whistling while you work

It isn’t often that I have something to be cheery about at work. Conditions in England’s NHS aren’t generally conducive to smiling, spontaneous laughter or outbursts of song. UK radiology is in a particularly dark place at the moment. But the last 12 months have seen this particular radiologist quite bright-eyed and positively bushy-tailed at times. I have been known to whistle the odd merry tune apropos of nothing.

The reason for this uncharacteristic jauntiness is fairly simple. It wasn’t that we were lucky enough to recently fund five new consultant posts. It wasn’t the pleasant surprise at getting five applicants. It wasn’t the frank astonishment at appointing 5 highly promising individuals. It wasn’t the bewildering fact that they’ve all turned out to be absolutely cracking new colleagues. Admittedly this has helped but it isn’t the real reason.

The truth behind my buoyant spirits is moving into our new hospital building. It opened in May 2014 after 9 years of planning and building. Two distinctly down-at-heel old hospitals were merged into a single brand new huge building. It took 46000 cubic metres of concrete and 7000 tonnes of structural steel to build one of the largest buildings in Bristol, at a cost of £430m.

Part of the joy is the physical beauty of the building. The main atrium is 6 storeys of multi-coloured glass. Natural light abounds. Simply strolling through it puts a spring in your step. Installation art and courtyard gardens are around each corner.

The main atrium of the new hospital

Part of the joy is finally seeing what we planned so meticulously finally come to fruition. Our radiology department was highly engaged, unlike others. We spent countless hours with the architects and planners. There was table-thumping at times. We moved doorways by 5cm and light switches by less. It was worth it; we got the department that we needed. Moreover, all the design features that we insisted upon are now working like a dream. One of the planning team is fond of quoting, “People got the department that they deserved”, to which I smiled knowingly.

Part of the joy is a profusion of new scanners. The lengthy planning had blighted scanner replacement. We therefore limped along on some ancient machines. One famous 14 year old 4-slice CT had literally no original parts apart from the outer casing; everything had been replaced at least once. A 17 year old MRI scanner broke irreparably; it literally went ‘bang’ and that was that. The new hospital, however, was crammed with gleaming new machines. We stared, slack-jawed and drooling. 

Part of the joy is ergonomic PACS stations. We designed a suite of identical reporting rooms with highly adjustable chairs and tables. They are immensely comfortable - a prolonged reporting session no longer feels like a physical chore.

Part of the joy is the direct adjacencies. The main radiology department is literally at the centre of the hospital. Nothing is far away. Our admin office is next to the reporting suite and opposite the secretaries office and the coffee room. These four points form a holy quadrilateral, especially the latter.

Part of the joy is a hot:cold split. All clinical enquiries, trauma calls and urgent cases go to our separate Emergency Radiology sub-department. This is nested within the Emergency Department and is staffed 24/7 by registrars and 8-8 by consultants. We all work in shifts to make the intensity of the work bearable. The main department is therefore deliberately interruption-free by design.

Part of the joy is new facilities that we never had before. We built a huge interventional radiology (IR) unit. Specifically designed with 6 fluoroscopy rooms (including one hybrid theatre) and a 16 bed day case unit, patient throughput is slick and IR is now assuming its rightful prominence. Then there is the self-contained one-stop breast unit. And not forgetting the brand new PET/CT suite too.

Part of the joy is, bizarrely, an open plan office. Much feared but, in fact, a very sociable admin space. All 35 consultants share a large office with large south-facing windows. Quiet enough to get your head down but a colleague is always on tap for a second opinion. It has also brought us together as a group in a way that we didn’t foresee.

A single quote encapsulated all this the other day. One of my new colleagues said unprompted, “This must be the best radiology department in the UK”. I agreed, grinning. But then again he was one of our old registrars, so he would say that.