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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, 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

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