About Me

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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

Tuesday 30 August 2022

Radiology Report Bullshit Bingo

I proudly present to you "Radiology Report Bullshit Bingo" 

If you get a full line from a single report, beat that radiologist with their own shoes 

A full house in a single day from a single radiologist indicates they need to hand back their FRCR

Tuesday 17 May 2022

Living in Interesting Times

There is a common myth of an old Chinese curse that runs, “may you live in interesting times”’. Although it isn’t old or Chinese, it seems apt to describe the last few years. I can barely remember the simpler and more care-free times before 2020. All the things we took for granted, all the things we missed so much in various lockdowns are slowly returning. Many of us had never seen viral pneumonitis back then. Many of us never want to see it again.

The covid pandemic is by no means over and it may never truly disappear but there have been many curious changes of the last two years. In the early days of the pandemic I wrote about our early experiences. Two years have elapsed since that time and a lot of medical water has passed under the covid bridge in the interim. Some of this has been revelatory, some of this has been, frankly, a pain in the butt.

The On-Line Life

Everything went on-line. Meetings, teaching, conferences, social life, everything. Initially, this was all rather novel as we discovered, for example, the hazards of leaving our camera or microphone on when we really shouldn’t have. For me, the novelty evaporated within a week. I have come to absolutely loathe on-line meetings with a passion.

I can see the practical advantages of not having to schlep across the country or to another country, specifically for introverts, the mobility-impaired or those with childcare commitments. Having this as an option is a positive step and I hope hybrid conferences are here to stay.

However, there isn’t the engagement of a face-to-face meeting, there isn’t the same emotion or nuanced communication, there isn’t the gossiping over a coffee between sessions. I mean you can sit in your underwear and still take part but that is little solace to a gregarious soul like me.

On-line teaching is very difficult to make effective. Most on-line courses or conferences are just a series of videos. Not all, but most. To me, that isn’t a course or conference. Most people would be much happier browsing YouTube instead. I went to my first face-to-face conference a few months ago and it was a tonic for the soul; so refreshing and reinvigorating.

Delivering on-line lectures is a personal bĂȘte noir. I was asked recently if I’d do an on-line lecture and replied, with a twinkle in my eye, that I’d rather do the splits on a barbed-wire trampoline.

Home working

If they had home reporting, many radiologists in the UK were barely seen in the department. Some didn’t have home reporting and rapidly deployed it for all staff. Some didn’t: I worked in the hospital every day, as per normal. Many worked a hybrid pattern of some days at home and some days in the hospital.

The upsides of home reporting are legion: no interruptions, no commuting, flexibility in the working day, decent coffee and the ability to work in your underwear (again, not mandatory). The downsides are also manifold: isolation, fighting with dodgy IT and PACS, wearing out your favourite underwear and increased pressure on your colleagues in the hospital.

This last point is crucial. Those left in the department were snowed under. Clinicians complained when radiologists weren’t available for discussion. Our trainees felt abandoned. In many hospitals, face-to-face checking and supervision evaporated, adding to the misery of lockdown.

It isn’t surprising. This is inevitable when a radiology department has only a … erm … skeleton staff.

Woeful Mitigation

Masks became politicised, almost a partisan topic. Which is clearly a failure of political leadership, with stupid individualism trumping sensible collectivism. And because the UK Govt has declared “covid is over”, the general population has now almost abandoned them. Which is bizarre, given they are the cheapest and most effective method of reducing infection.

Speaking of which, the use of High Efficiency Particular Air (HEPA) filtration has been almost ignored. A proven method of almost eradicating viral bioaerosols, shouldn’t every office, every reporting room and every scanner have a portable device? Why aren’t we retrofitting centralised air conditioning units with them? Everyone benefits from cleaner air. I can’t understand this.

We used masks by the billions and, inevitably, the tonnage of plastic waste has been huge. The focus on hand washing was an unusual choice for a disease spread by aerosol but not entirely without logic. However, the focus on single-use gloves and plastic pinafores was frankly ridiculous. Coming a time when the climate crisis is in full swing, this has been difficult to swallow.

I don’t want to be too political but high level UK Govt policy about contact tracing and private providers of PPE have revealed corruption on a utterly unacceptable scale at the highest levels. Billions have been frittered away. The hasty construction of the almost entirely unused regional series of ‘Nightingale’ covid hospitals was a scandalous failure of logistics. Millions were wasted. No one has been sanctioned or even vaguely chastised. We have been very forgiving. Either that or we’ve been completely hoodwinked. Or both.

The Red-Tape Bonfire

Desperate times allowed desperate measures. Normal rules and normal procedures were ripped up in the name of covid and expeditious decision-making. This brought enlightenment and despair in equal measure.

Redeploying radiologists into the clinical arena was a frank mistake. I wasn’t affected but many were. I know I would have been a positive hinderance and many reported the same frustration. Fortunately this was short-lived and hopefully will never be repeated.

In the UK, annual appraisal and revalidation programme was suspended and the burnt-out mess that is the consultant workforce let out a collective sigh. What happened? The world did not come to an end, the seas neither boiled nor dried and the land was neither ravaged nor pillaged. Some commentators asked serious questions about the validity of this widely-loathed, paperwork-heavy system.

What next?

Although the quiet times of the initial lockdowns allowed a pause to catch up, reflect and solve issues, I’m sad to report that UK coal-face radiology is now in no better position that it was in 2019. All the adulation for the UK’s NHS in the early pandemic, all the ‘clapping for carers’ was, sadly, an empty populist charade.

Our NHS scanners have never been busier, our workforce has never been more exhausted. With the UK economy as it is, there is no magic wand, no secret potion, no Fairy Godmother coming to our rescue. So, until the magic radiology tree starts bearing fruit, all we can do is grin, cope and lobby for more staff and more resources.

Thursday 27 January 2022

Getting Things Wrong

In recent years I’ve realised that I’ve been doing things wrong. Not just as a radiologist but also as a human being. I thought I was up-to-date and doing the right things but I wasn't. It wasn’t that I’ve had my head in the sand; I am rampantly curious and very open to new ideas. Naturally, I’m intensely sceptical. Actually, battle-weariness may be closer to the truth.

It has been a slightly painful dawning realisation. Several factors have contributed to my slow awakening. Partly it has been discovering differing but compelling voices that have changed my mind. Partly it is mid-life introspection, peeling away the onion layers of my world view and finding some of the inner layers are unsavoury. Partly it has been lively friends and colleagues that have kept me on my toes. Partly this has been my darling spouse and teenagers that consider it a devotional act to remind me of my flaws on a daily basis.

Some has simply been listening. In recent years, I’ve been learning from those talking about kindness and compassion and those addressing injustice and inequality. Leaving your mind open to new concepts is crucial if you don’t want to ossify. There is no point yearning for earlier simpler times; they don’t exist, that was merely our ignorance of their complexities. For me, it’s a part of a life journey, seeking to be a wiser and better human being. The side effect is that you might just become a better radiologist too.

Just occasionally a realisation is epiphanic. You learn something that is a metaphorical whack on the side of the head. Your previous assumptions, knowledge or attitudes were way off. It is a ‘eureka’ moment, both tremendously exciting and faintly disturbing. The best sort of brain jolt is where an age-old notion is overturned. A concept that you hadn’t thought to question, a self-evident fact, is suddenly turned upside down.

I’ll give you a professional example. On day one of radiology school we learnt about the cardiothoracic ratio. We have subsequently dutifully measured it and included it on countless thousands of chest radiograph reports. Except that 102 years after it was first described, two papers (1,2) show it to be useless, singularly lacking in sensitivity and specificity for actual cardiomegaly.

Given that the evidence-base for much of radiological practice is tissue paper thin, it set me thinking about what else that we do is frankly wrong. Probably much more than we care to admit. Whilst debunking age-old assumptions is refreshing, it is galling that realise that we’ve been doing it wrong for over a century.

I have had innumerable non-professional moments where I have felt that the fog has suddenly lifted and I have seen something with utter clarity. These are ‘threshold concepts’: an idea that, once grasped, leaves you transformed and unable to see the world in the same way (3). An example is when I first heard the phrase ‘You aren’t throwing something away, you are just throwing it somewhere else’. A lightbulb pinged on somewhere in my head. I’m now a ruthless recycler and an aspiring reuser and repairer. But I’ve felt guilty about every single black bin-bag ever since.

So what do we do with such personal transformations? What action do we take armed with better information? Surely it is all to no avail if we simply shrug and take no personal action? We must encourage others to change their ways too. It’s relatively easy to get radiologists to change their ways. Admittedly, the cogs of the NHS turn at a glacial pace. For example, it took several years but relatively little persuasion to change from barium enemas to CT colons, venograms to dopplers and IVUs to CTUs. We just needed different scanners and more staff.

It isn’t so easy to get society and government to change. We are a long way from global enlightenment about reversing the harm we are inflicting on our planet. You don’t have to be George Monbiot to realise we have to change our ways and need to do so very rapidly. Witness the uncharacteristically direct action of many climate campaigning doctors, joining Extinction Rebellion in their programme of Civil Disobedience.

As a Yorkshireman I get likened to a Scotsman with all the generosity taken out. But the inherent thriftiness of 5.4 million Yorkshire folk is now mainstream and relevant. Turning the heating down, reducing food waste and methodically switching off unnecessary lights is no longer a childhood memory but very much in vogue. Commenting that ‘it’s like Blackpool illuminations in here’ is optional but an almost obligatory part of being a middle-aged parent.

We need more than personal action, we need systematic change. I can say ‘if you are cold then put a jumper on’ a million times but when half the NHS estate leaves it’s lights blaring all night and the heating on full in summer, I know we can do better. The volume of single-use, non-recyclable plastic the NHS uses is preposterous, most recently in the form of ridiculous volumes of plastic aprons and gloves that do nothing to combat a famously airborne virus. The NHS is waking up to sustainability but it is way behind the curve.

We radiologists can raise our game. There are easy wins - exactly why aren’t all PACS workstations and lights turned off at the end of the day? Some are more challenging. IR has a big waste problem; a single procedure generates at least one bin bag of plastic refuse. Catheters and other kit need longer shelf-lives, there is so much waste even with careful stock control. Our focus should be away from speed and power to efficiency and sustainability.

It is frustrating knowing that we are doing things wrong, knowing we could do better but feeling that the system isn’t changing fast enough. Maybe it isn’t so crazy to take extreme action. I might just glue my hands to a CT scanner tomorrow.

1) Simkus et al. Insights Imaging 2021, 12: 158
2) Torres et al. CMAJ 2021, 44: E1683
3) McCoubrie P. Threshold concepts and the ha-ha effect. RCR Newsletter Spring 2012, Issue 105, p10