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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

Thursday, 13 December 2018

Radiology On-Call Bingo

Radiology on-call getting you down? Just about to snap? Notions of civility evaporating as the shift progresses?

Fret ye not. I give you "Radiology On-Call Bingo", the answer to your woes

Four rows and you get an honorary FRCR. Full house and you get your CCT

Sunday, 11 November 2018

Even More Rules of Radiology

Over 5 years since the original 42 rules and 3 years since the follow up, I proudly present the third (and final) instalment of Rules of Radiology. These 100 truths encapsulate all that is important in our beautiful speciality. Acting as a rare beacon of light in these dark times, they provide a clear moral and behavioural codex, appropriate for radiologists of all vintages. 

The first 50 Rules have now been turned into book - available for you to buy or download


Rule #69 / / Radiology is extrapolating from a screen grab
If life is a box set and illness is a single episode, radiologists are left to infer the plot from a single screen shot. This explains why radiology is so damned difficult sometimes

Rule #70 / / Coffee should be taken black
Coffee is the lifeblood of radiology, our dominant fuel source. Thus the Bean should be treated with total respect. Never ever syrup, sugar with caution, warm milk only in extenuating circumstances

Rule #71 / / Radiology reporting is like playing golf in the dark
Your swing may be sound but you have little idea of where the ball lands. Clinico-pathological feedback is a radiological imperative. Without it, all confidence is misplaced

Rule #72 / / Never report ‘no change’
It is a supremely unhelpful radiology report. It is only permitted in one specific circumstance - when reporting an x-ray of a child looking for swallowed coins

Rule #73 / / Always report in date order
The oldest studies get done first, irrespective of their complexity, image quality or indication. Cherry picking is the mark of a lazy and selfish radiologist

Rule #74 / / Beware the radiologist with a zero % error rate
It either means they are (a) perfect (b) doing no work or (c) being dishonest. Given (a) is impossible and (b) is unlikely it means that (c) must be true

Rule #75 / / Interventional radiologists don’t need to care
Technical ability always trumps empathy and communication skills. The heart of an IR doesn’t need to be in the right place but their lines should be

Rule #76 / / Radiology should be fun
Radiologists are medicine’s dolphins, frolicking in its warm waters. If it doesn’t feel like fun then you need a holiday. Failing that, move to a hospital where you are valued

Rule #77 / / There is no such thing as a ‘naturally gifted’ radiologist
Natural talent is a myth. Show me a talented radiologist and I’ll show you someone who works their socks off. Show me a duffer and I'll show you a sluggard.

Rule #78 / / Introduce yourself
Just because you are a radiologist doesn’t mean you are above common courtesy. Greet patients and staff by turning to them, smiling, fixing eye contact and proffering a brief but firm handshake whilst saying “Hello, my name is …”. Do this every time. Especially the last bit

Rule #79 / / Trust in chronometry
Those that take twice the time to report their scans are half as good. The corollary isn’t true. Those that take half the time to report their scans are also half as good. 

Rule #80 / / Ignore 3D recons
No self-respecting radiologist would ever use them for primary diagnosis. And, no, they aren't interesting or clever either. They are mere pretty baubles to keep the surgeons happy

Rule #81 / / AI is overhyped 
Whenever anyone says AI will replace radiologists, you have my personal permission to beat them with their own shoes

Rule #82 / / Do the simple things well & often
If you are courteous, honest, well-presented, organised, methodical and work with a slick team in a clean environment, then you are >90% of the way there. Heroics are rarely necessary and paradoxically unhelpful

Rule #83 / / Show yourself
An invisible colleague is an annoying colleague. Beavering away in a quiet corner mustn’t be the default. If you can’t be found easily, you aren’t doing your fair share. Step out of the shadows and pull your weight.

Rule #84 / / Don’t criticise colleagues
It is unwarranted - they are usually trying their hardest. It is unhelpful - a knife in the back helps no one. It is destructive - it sours relations. A good radiologist leads by example and encourages others

Rule #85 / / You can only eat one breakfast
Quality of life & happiness barely increase as income rises >£50k. And yet monetary squabbles are a common cause of rancour between radiologists. Rise above this. If you are in it for the money, you are in the wrong trade

Rule #86 / / You Will Learn to Hate VR
Yes, yes, yes; voice recognition has brought some benefits. However, it turns most radiologists into expensive secretaries. And nothing in your working life is quite so annoying, quite so often

Rule #87 / / Dress smartly
The vogue for dressing down is to be resisted. You are a doctor, dammit; dress like one. The less formal your clothes, the less respect you'll get. If you look like a scruffy overgrown teen don't complain when you are treated like one

Rule #88 / / Focus on the gaps
Time taken to report a scan or perform a procedure is irrelevant. It is a statistic, not a quality measure. Some scans take longer. Some people take longer. The time wasted before and between scans or procedures should be the focus

Rule #89 / / Eminence doesn’t equal sense
Confidence wears off slower than skill in the aged radiologist. Grey hair and notoriety doesn’t mean infallibility. Often the opposite.

Rule #90 / / Sloppiness is infectious
People inherently cut corners. Sometimes it is because they work in a crap system. Sometimes it is because they are lazy. Don't just shrug complacently - do something. The standard you walk past is the standard you accept

Rule #91 / / Never assume relationships
An attractive 20-something with a frail octogenarian are usually grandchild & grandparent. But the one time you voice this, you can guarantee that they'll be married. Avoid foot-in-mouth disease:- always ask

Rule #92 / / ‘Order Comms’ must be loathed
First, no radiologist should let themselves be ‘ordered’ to do anything. Second, one-way transmission prevents clinicoradiological discussion. Last, it denies a key perk of the job as there is no physical card to rip up

Rule #93 / / Don’t blame the ‘bad apple’
Improvement by removing a 'bad apple' from the barrel is a fallacy. It is virtually always a barrel issue. It is just that apples are easier to blame. An enlightened radiologist blames neither: they learn, they improve

Rule #94 / / Structured reporting is overblown
Structure in reports is always good but structured reports aren’t always good. Such reports are over-long and mind-numbingly bland; the antithesis of a readable report. And an unreadable report is a dangerous report

Rule #95 / / Beware pixel-squeezers
Some radiologists will try to convince you of the significance of tiny isolated abnormalities only a few pixels across. Or worse, minor variations in the shade of faux-colour. You can safely ignore them; they are making it up

Rule #96 / / Embrace Productivity
Attempts to improve productivity are normally just harder cracks of the same whip. This achieves nothing apart from burnout. But looking at ways of achieving the same goal more easily and effectively indicates enlightenment

Rule #97 / / Be a kind boss
Radiologists can find themselves in leadership positions, often accidentally. Be the boss you would like to have had. You can be decisive and effective and yet remain kind. Whereas inhuman autocrats are toxic, ineffective and hated.

Rule #98 / / Embrace Diversity
Great departments are staffed by radiologists of varying age, gender, race, culture & personality. This serves both referrers & patients well. But coherence is vital. It falls flat if you aren't all pulling in the same direction

Rule #99 / /Look After Yourself
You cannot escape the anxieties incident to professional life. But when going the extra mile becomes the norm, you are on the road to burnout. A burnt out radiologist is tragic: tragic for themselves, tragic for their patients

Rule #100 / / It’s all about the patient
It isn’t about you, the referrer, the institution or the health system. It never was and never will be. Each and every act of a radiologist should directly benefit the patient. Lose this principle and you lose everything

Thursday, 22 February 2018

The Unreasonable Radiologist

Radiologists used to be gatekeepers. When I was in short medical trousers each hospital had one CT and one MRI scanner if they were lucky. Getting a scan was near impossible. Getting an urgent scan was laughable. We joked that the urgent scan requests had to be signed in blood of the requesting doctor.

A wise radiologist told me 90% of the job at that time was ‘sitting in the dark, telling people to ‘eff off’. Whilst only partially true, it was a necessity. On a good day we would scan 15 patients. CT scanners were slower than MRI is now. MRI was so slow that patients could develop metastatic disease during the scan.

One of my old bosses was known hospital-wide as ‘Dr No’. It wasn’t that she was an evil mastermind or had a rubber arm or anything. She would simply fix the quivering junior doctor with an unblinking stare, say a firm “No” and that was that. No other words were necessary. Moments later the request form fell in shreds into the dustbin, providing the cue for the requesting doctor to exit apologetically.

This gate keeping role has virtually evaporated in the UK. The investigational chocolate box is wide open. Clinicians can help themselves to as many scans as they like, as often as they like. Radiologists rarely refuse. It actually takes longer to say no to a scan than do it. Which is all manner of wrong, of course.

Some people say that better access to scans meets an unmet clinical need. Doing more scans is therefore better clinical practice. However I cannot shake the feeling that we are doing more and more scans and finding less and less. Pre-test probability means absolutely nothing in modern clinical practice. Our glorious diagnostic service is rapidly becoming a screening service.

As a result, UK radiology is currently in a dark place. Whilst demand and expectations have soared, numbers of radiologists and funding haven’t, leading to the current ungodly mess. And, because fairy godmothers don’t exist, we’ve somehow got to sort it out.

I would advocate that we need to all become a little more ‘Dr No’. We need the wisdom to distinguish clinical demand from clinical need. We need the senses to recognise bovine excrement. We need the conviction to denounce it. Admittedly this flies in the face of modern socio-medical trends where medical paternalism is frowned upon. But sometimes radiologists do know best.
The only way to report - with fire in your belly

Radiologists need to regain a little fire in their bellies. We should be bold and decisive, borderline unreasonable. As George Bernard Shaw said, “The reasonable man adapts himself to the world: the unreasonable one persists in trying to adapt the world to himself. Therefore all progress depends on the unreasonable man.”

“But how?” I hear you cry. Well, the easiest tactic is just to withdraw scans that are a waste of time. We’ve recently stopped offering CT of the abdomen for unprovoked VTE. I heard of a place that doesn’t do MRI knees in the over 50s. Simple stuff. No discussion. Just a firm party line. 

This fight cannot be won by policies and protocols alone. There will always be personal interactions between radiologist and clinician. And there, I argue, it is beneficial to be borderline unreasonable. Unreasonable, yes, but at least civil, preferably polite and ideally friendly. Radiologists across the UK have a reputation of being rude, dismissive and aggressive, particularly to junior doctors. It is an understandable; radiologists are under intolerable pressure and lack any semblance of support. 

We aren’t all rude but we aren’t always as polite as we could be. Workplace incivility creates a toxic atmosphere that demotivates and distresses. The modern NHS is an uncomfortable bed without us soiling the sheets. Furthermore, venting anger is counterproductive - it fuels aggression rather than dissipating it. Research shows that rudeness is also associated with poor patient outcomes. It is thus incompatible with a good quality of care. It belongs firmly on the dung heap of radiological history, next to barium enemas.

One gambit to is to employ ’the paradoxical consultation’. In this encounter, you disarm the requesting doctor with a smile and invitation to sit, briefly listening to the history before explaining that a scan is quite unnecessary but giving them a firm plan about how to manage their patient. They leave the room happy, smiling and grateful. You feel satisfied too. Only later do they realise that, in fact, you just told them to sod off and they thanked you for it.

So, armed with this fresh-faced and uncompromising approach, I honestly believe we can confront some of the problems in UK radiology. Saying ‘no’ isn’t necessarily negative.