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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 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.