When I was a med student, the Beating Heart of the Hospital of the University of Pennsylvania (HUP) was not the CEO’s suite, the neurosurgeon’s OR, or the Dean’s lair. It was the seat of one Wallace Miller, Sr., in the decidedly unglamorous Chest Reading Room.
Do you even know where the chest reading room of your radiology department is?
Everybody – and I mean everybody, from the lowliest student to the seniorest clinician – brought their films to “The Wal” to figure out what was going on. For students like me, the trip to Mecca was both fun and terrifying. “What’s this opacity?” he asked me once, the memory seared in my medulla oblongata. “A… a pneumonia?” I stammered. “Mooiaaa” retorted the Oracle, turning his head away in mock disgust. I loved it.
One night last week, my ward team got 8 new admissions. After sprinting through the H&Ps and doing a little teaching, I suggested that we head to the radiology department to review the key films. I might as well have asked the team to hop on one foot and cluck like chicken. They humored me, but it was clear that they saw this as an odd, and rather unusual, request.
Contrast this with attending rounds in the Days of the Giants, in which the attending could no more skip radiology rounds than the med student could skip the patient’s social history. After reviewing the new admits, we all trekked to Radiology to review the films, each ward team passing through like cars in a car wash. Back then, this was all accomplished in a single reading room, since virtually all the films were of the thorax. The KUB didn’t show very much, the CT was a grainy daguerreotype, and magnetic resonance was what you learned in Organic Chem.
This review of the films was collegial, educational, and fascinating. It also provided focus and direction. “This is a 52-year-old woman with lupus, shortness of breath, and fever. What do you think, Wally?, we asked.” “Well, might just be the atelectasis of lupus lung, but it looks a bit hypovascular on the right side. Is she at risk for a PE?” The back-and-forth brought the clinicians ever closer to a thoughtful plan or a correct diagnosis.
We went to the Radiology Department for all these wonderful interactions. But we also went there because we wanted to look at our films.
In my last post, I wrote about how the electronic medical record has de-tethered – I call it “dis-located” – providers from the patient floor, since the docs no longer are hostage to a paper chart. The same type of dis-location – this time brought to you by PACS – allows us to review our “films” without ever stepping foot in the radiology department. In my 2006 New England Journal article, I considered the other key implication of this dis-location; namely the emergence of teleradiology, including the cross-border variety.
Lest you think I’m a total Luddite (I do have a blog, after all), you should know that I think that digital x-rays are a good thing. But the fact that we no longer have to go to radiology to see our films has real consequences. And this is why, when my teams do take the time to visit the radiology department, I conduct a little sociology experiment with them. Standing outside one of the reading rooms, I say something like this:
“Watch what happens when we enter. Does anybody turn around and welcome us, ask ‘how can I help you?’ and seem genuinely enthusiastic? When they go over the film, do they delve a layer deeper than the dictated reading? Do they make any teaching points? Does the radiologist suggest courses of action or ask provocative questions?”
In UCSF’s radiology department, a visit to our neuro reading room always results in “yes” answers to all these questions; which is why I always look forward to these visits.
But some areas of our department have traditionally had a different culture. I won’t say which one or ones – in part because all of them have become more service-oriented in the past few years (for example, on two visits last week, one of the prior problem areas was spectacular), for which I am grateful. But the bad experiences still occur from time to time; they’re easy to recognize. They look like this:
I tell my team to enter the room but then to stand near the door, silently, and simply observe. The first thing you notice is a sea of backs – no radiologist turns around. (Has the entire radiology department been in a bus accident, their necks in cervical collars?) After a couple of awkward minutes, one of the radiologists begrudgingly rotates (has his C-spine been magically cleared?) and notices us. “Oh, do you need something?” No, we got lost on the way to the morgue, I nearly blurt, but I restrain myself. “Sure, can you help us with some films?” He does, sorta, but the reading is stilted, devoid of enthusiasm, in a passive whisper. Sometimes the passivity reaches phantasmagoric proportions, as in: “We don’t see an infiltrate.” I can’t help but wonder who this “we” is – is the ghost of Roentgen sitting on the radiologist’s shoulders?
Then, just when I think it can’t get any worse, it does. “What do you think of this area?” I might ask, pointing to a confusing patch of whiteness. The response: “Did you look at the official reading?” In other words, are you an illiterate moron?
The mostly unspoken message from this un-Passion Play is: “Get out of my space, I’m busy.” Now, I understand that – the radiologist might well be busy, and it has to get a bit annoying having clinicians interrupt you every few minutes to go over films, particularly after you’ve just reviewed the same ones with the pulmonary or ID consultants. But that is the radiologist’s job, and last I checked they are compensated reasonably well to do it.
I only make a fuss over this because I believe we are at a Tipping Point in this particular part of the Medical Universe. We are now training the first generation of clinicians who will never experience the need to go to radiology to review films. Whether they do or don’t visit the department and interact with radiologists will be entirely determined by the quality of their experiences when they do make the effort to go.
In my NEJM article on dis-location, I described the growing teleradiology trend, driven by the fact that the same technology that allows me to read my films without going to the radiology department also allows a radiologist in Banglaore to read a film as easily as a radiologist in Bangor. The Indian radiologist earns one-tenth of what the U.S. radiologist earns. If my experience in visiting Radiology World tends to be of the positive, collegial sort, I’ll fight like hell to keep the radiologists in the hospital. If it feels like I’m distracting them from their “real work,” then (assuming comparable technical competency) there’s no reason for me to care whether they are in the building.
Or the country.