There Was a Time When Radiology Was Rational

At a meeting of fellow financial advisors, a speaker recommended a book entitled “Checklist Manifesto” by Atul Gawande. Since this book was recommended in conjunction with my financial advisory practice, I was surprised to learn that Gawande is a surgeon and actually wrote the book as the result of a World Health Organization project to reduce operative mortality. Another blog in this space by Dr. Woodcock has already extolled the virtues of utilizing checklists in radiology.

Dr. Gawande gave many examples of how checklists can make complex processes safer and more consistent. One such example concerned building huge sky scrapers. There was a time in the not too distant past when a master builder could supervise the building of structures from concept to final construction, providing knowledgeable oversight throughout each phase of the building process. Because of the complexity of modern buildings, such a “master” builder is no longer possible and each and every aspect of building requires its own expert builder and exhaustive checklists and timetables to ensure a successful completion of the project.

Dr. Gawande observes that modern medicine is still practiced using the “master builder” model. Even though most physicians don’t have a detailed knowledge of medical imaging, with its indications and limitations, they order large batteries of imaging studies, without apparent concern for imaging efficiency or appropriateness. This approach is counterintuitive at the very least and downright dangerous on occasion. It definitely seems to be at odds with the concepts of “accountability” and “medical necessity.”

Back in the early 1980s during my pediatric radiology fellowship at the Children’s National Medical Center in Washington, D.C., I enjoyed the experience of working with and learning from some excellent physicians, both radiologists and pediatric specialists. Ultrasound, CT and angiography were fairly new in pediatric radiology. For instance, I remember forming catheters over steam because there were no preformed angiographic catheters. I also remember receiving radiology requests stating “Two-year-old male with abdominal mass. Please evaluate.” The radiology residents, fellows and attendings would then put our heads together and decide on the optimum imaging workup to reach an imaging diagnosis for this particular patient. Diagnoses were frequently made within hours. There was never any concern that we were self-referring or churning studies. Problem presented. Appropriate imaging performed. Problem solved.

Such a rational approach to diagnostic imaging is unimaginable in today’s medical environment. In fact, current electronic order entry systems with extensive imaging menus being input by ward clerks or nurses makes selection of the most appropriate imaging studies highly unlikely. While a few physicians take the time to discuss their difficult patients with us and plan a logical diagnostic imaging sequence, most don’t have the time or inclination, or only call to discuss the results of the studies they have already ordered.

There are many times when I just shake my head and realize that instead of being a “master builder” or even someone at the table with input on the project, I am actually more like a brick mason, laying brick after brick from a pile that somebody else has stacked for me.