Radiologist, Are You Consequential?

At a level-one trauma center I covered in the murky past, nighttime ultrasound was almost as rare a commodity as MRI, in that most formal exams required summoning the sono tech on call into the hospital. 

The exception was what has subsequently been named the FAST scan for free abdominal fluid; in the setting of trauma, the on-call radiologist (covering the entire hospital, ER and all) would personally do the study.

Initially, my lack of enthusiasm for this protocol was based on the hassle factor. While I was wheeling down the old, clunky sono unit from a locked closet in the radiology department to the ER (newer units were not to be risked, nor was the ER to be trusted with a machine of their own), performing the scan, and then bringing back the machine so I could upload the images, all sorts of backlogs in my workload would develop.

However, a more significant dissatisfaction soon took center stage: My findings (or lack thereof) had absolutely no effect.

The rationale for the scan, as explained by the ER docs, was that if free fluid was seen, the patient would be taken “straight to the OR,” without further evaluation. Of course, 99 times out of 100, there was no free fluid, and so I would proceed to see a head-to-toe CT on the patient shortly thereafter to check for more subtle pathology.

So, on the rare occasion that I actually saw free fluid, I was mystified when the patient didn’t get whisked off to the OR, but rather wheeled down to CT in precisely the same way as if no fluid had been seen. When I asked the ER folks why this was, the answer was, “We need to see where the fluid is coming from.” Nobody could explain what actual purpose the ultrasound had served.

I developed a similar sense of inconsequentiality in the realm of spinal X-rays, mostly of the neck. A typical trauma case would generate a limited C-spine series, to be followed by a more complete set of films if normal, or a CT if not. That made sense to me; if I could see that things looked normal by X-ray, there was no need for advanced imaging.

But as months and years went by, it became the case that, no matter how pristine and normal the X-rays looked, a CT was inevitable. One would think that the plain films would eventually be discarded entirely, but they remained routine. I just didn’t know what purpose they (or I) served. If they were abnormal, a CT was done for greater detail. If they were normal, a CT was done in case the X-ray missed anything.

If the long and challenging process of educating and training radiologists hadn’t made a point of selecting for intelligence, decisiveness, and dare I say leadership, I suppose it would be easier for us to take such things in stride - keep our heads down, accept whatever work we’re given, and don’t ask questions that might challenge and/or annoy the folks giving us our marching orders.

As it stands, we generally seek to have an impact on things. We want to know our inherent talents, developed skills, and applied efforts are making a difference, if not being met with some appreciation from those around us. This isn’t limited to interpreting images well and having a positive influence on patient care. We also feel satisfaction when our thoughts on departmental organization and protocols are heard and result in decisive action - and frustration when our input is disregarded.

Met with such frustration, a radiologist tends to have two choices: Stay put, and endure being a cog in someone else’s machine (or hope that things will eventually change), or move on and find a position of greater consequence. Needless to say, the latter option is harder in the current tight job market. I suspect a larger proportion of folks are thus staying put nowadays, and suffering in silence - or maybe not so quietly.

Those in leadership positions would do well to recognize this. Better morale on one’s team tends to result in a more pleasant, and even more effective, work environment. And even if one enjoys lording it over a group of downtrodden peers, it’s worth remembering that job markets do turn around. When they do, folks are only going to stay on your team if it’s giving them what they need.