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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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Very interesting , invaluable rules, especially when it comes from some one whol himself applies to his work.
ReplyDeleteThanks Paul,was a pleasure working with you.
Thanks Hala, always lovely to hear from you, especially such kind words too!
Deletegreat tips
ReplyDeleteBy your picture, i would not expect so much wisdom. You really seem young!
ReplyDeleteOr maybe I should try glasses
DeleteVery kind. I'm 49. Not old enough to be wise but old enough to know better!
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