Ken Keller, MD

Another October has rolled around and we are immersed in all the various “pink” campaigns to increase breast cancer awareness and the value of mammography for early detection of this common disease. Many of us will wear pink, make public appearances, have different speaking engagements or be interviewed on radio or television. Many Americans will contribute millions of dollars to any number of different fund-raising activities for breast cancer research. As a former supervising radiologist for the mammography department, I willingly volunteered for these duties for many years. I’m sure hundreds (or thousands) of radiologists have done the same over the years. Kudos to all of you for your efforts!

However, I recently got to thinking specifically about this perennial phenomenon and more generally about this disease. The American Cancer Society still says that the chance of a woman getting breast cancer in her lifetime is one out of eight.  Despite decades of experience and improvements in imaging techniques, the incidence of breast cancer hasn’t changed over the past three decades. Clearly early detection is critical, but come on colleagues, is that the best we (in medicine) can do?

While we may lack understanding of the specific cause of this disease, the argument that we don’t know how to prevent breast cancer is both specious and ubiquitous. It is easy to sit back and say “We just don’t know what causes breast cancer, so make sure you get your annual mammogram so we can find it early.” For years that is what many of us have done and continue to do. Our female patients and, particularly, the women in our lives deserve better.

There are a number of things that we, as radiologists, can do to aid in prevention. Because of our role at the forefront of breast cancer detection, we are superbly positioned to increase patient (and public) awareness of not only the benefits of early detection through mammography, but also

 of the disease in the first place. With respect to prevention, we should be speaking out whenever we can, rather than acquiescing. We should promote healthy lifestyle changes such as maintaining proper weight control and regular intentional exercise, reducing processed food intake, avoidance of GMO products, and increasing dietary consumption of turmeric/curcumin and omega-3 fatty acids.[[{"type":"media","view_mode":"media_crop","fid":"53297","attributes":{"alt":"Breast imaging","class":"media-image media-image-right","id":"media_crop_6547036533927","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"6644","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 170px; width: 170px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Â©karelnoppe/Shutterstock.com","typeof":"foaf:Image"}}]]

However, recent high quality clinical investigation trials

 have revealed that the current best method of breast cancer

 is through proper maintenance of therapeutic serum concentrations of 25-hydroxyvitamin D which resulted in striking, statistically significant prevention of breast cancer in the study groups. This prevention is most easily accomplished by inexpensive dietary supplementation with vitamin D-3. However, regular blood level testing is necessary since there can be notable variations in serum concentrations even between individuals taking the same dose.

In radiology, many of us have taken pride in diagnosing a breast cancer in its earliest stage. How much more impactful can we be if we could

 it from developing in the first place? Beginning this October in Breast Cancer Awareness Month, I encourage all radiologists to get the word out to our patients and referring providers about breast cancer prevention as well.

Lappe J, Travers-Gustafson D, Davies K, Recker R, et al.

Articles

Radiologists can do more to increase awareness about breast cancer.

Increasing Breast Cancer Awareness, Prevention

It is likely this mantra has echoed around reading rooms all across the country. Although I’m no financial planner or lifestyle advisor, I have reached this critical juncture in my career and have repeatedly reflected on this subject. Through this process, I have learned a few caveats that I think deserve careful consideration by any radiologist contemplating “career conclusion” through retirement.

Many of us may be attracted to the concept of retirement with perceived enticements of no call, no meetings, no axe to grind, no (or less) responsibility, loads of free time, etc. Some of us may feel this idea actually resonates with our own future philosophy or our goal for how we want to spend the latter part of our lives. The only thing is that many of us who say we want to (or will) retire, don’t exactly understand what “retirement” actually means, let alone fully comprehend the ramifications of “giving up our day jobs.”

Perhaps the most important lesson I have learned as I enter my retirement is 

do not give up all of your active income. 

Although good general advice for anyone contemplating retirement, this is even more important for us as radiologists than for nonphysicians since we have become accustomed to a lifestyle that has traditionally been maintained by a large active income. We have become used to expensive cars, dining, traveling, entertaining, spending, and living in a manner that is not sustainable if we no longer have a similar level of income. Oh sure we can say we will cut back or scale down how we do things, but frequently those plans go awry.

Many retirees (and their financial planners) will say they have enough funds in various accounts that they can live off the proceeds. However, if you are forced to maintain your lifestyle from your profits, the manner in which you invest those funds will fundamentally change, because now you have no alternative source of income, since you cannot cover any losses with additional active income. Suddenly there will come the realization that there may not be enough funds to do the things you want to do as a retiree.[[{"type":"media","view_mode":"media_crop","fid":"48416","attributes":{"alt":"radiology retirement","class":"media-image media-image-right","id":"media_crop_9444949716689","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5770","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 122px; width: 179px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Â©www.BillionPhotos.com/Shutterstock.com","typeof":"foaf:Image"}}]]

Fortunately, radiology (in retirement) offers a unique position in the medical marketplace since we can “work” long after many other physicians have felt the need to physically retire. We don’t have to lift heavy things. We don’t have to stand in the OR all day long. We don’t have to answer to the rigors of an office full of patients. We don’t have to be awakened from sleep to work.

I am not suggesting “retiring” to go to work for a teleradiology company. Teleradiologists that I know work hard and typically work several hours a day, several days consecutively, followed by a similar number of days off. Week in, week out, month in, month out…that’s not my concept of retirement and I doubt any of those that do it would say they are retired. However, there may be a few companies that have small niche opportunities for part-time teleradiologists who don’t have such rigorous schedules.

Or, there may be local opportunities that have occasional coverage needs, perhaps to cover vacations, conferences, meetings, or even leaves of absence. Radiology circles are relatively small and almost all of us know lots of other rads or practices that might lend themselves to create arrangements where decades of experience can be brought to bear in a productive manner, perhaps even teaching at some level.

Unlike CT scans and other on-call exams, these “retirement” opportunities will not be relentlessly incoming, but the inquisitive and insightful radiologist will be able to uncover such situations. They may be a week, a month, or even every other month, but it may be just what the rad ordered to properly “cash flow” the bills of retirement in a way that makes life after retirement that much more enjoyable and sustainable.

There are options for radiologists regarding retirement.

So You Want to Retire

There’s been recent media attention on participation trophies and ribbons for children’s athletic activities. Various professional athletes have claimed these awards are overdone since the majority of these “pediatric players”, including their own children, have not won anything and, therefore, not earned them. The polar opposite position is played by executives of various trophy and award companies that are trying to improve their bottom lines by claiming this practice improves kids’ self-image since we are trying to cultivate well-adjusted teens and adults as they enter into various societal and workforce games played by all of us.

The parents of these participants are typically somewhere in the middle of this milieu as they try to weave their way through parental guidance of their children in hopes that their kids will grow up to be self-sufficient, well-adjusted, contributing adults in society, knowing full well that the vast majority will never play competitive sports.

This phenomenon got me to thinking. Although the majority of radiologists will never practice “competitively” (such as) writing papers, serving on boards or committees that decide important or specialty-influencing issues, or advising leaders that shape national policy, shouldn’t we all be recognized, just the same? Shouldn’t we all get participation awards? After all, we try hard, almost every day. We try to come to work on time, try to avoid long lunch breaks and be considerate of our colleagues.[[{"type":"media","view_mode":"media_crop","fid":"40996","attributes":{"alt":"trophy","class":"media-image media-image-right","id":"media_crop_6412421547164","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4256","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 160px; width: 160px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Â©Dacian G/Shutterstock.com","typeof":"foaf:Image"}}]]

We participate in daily reading, committee meetings, and tumor boards. We participate in the call schedule, curb-side clinical consultants, and the occasional spontaneous media spot promoting our latest imaging modality, explaining how it will help us better serve our patients and our committees. We contribute our thoughts, opinions, and suggestions when asked, and occasionally even when we are not asked. We may even contribute our dollars to fundraisers and foundation activities.

Gee whiz, don’t we “deserve” some kind of participation award, trophy or ribbon for our efforts as radiology team participants? Tongue-in-cheek humor aside, I’d wager that many of us can recall (sadly) radiologists who do think we should be awarded simply for our participation in our day-to-day activities.

We should all realize that there are certain expectations and guidelines that should govern our participation in our daily radiology practices, regardless of what we do or where we are located. Common to all practices should be open communication between all associates, consideration of the others’ positions and situations, timely arrival and departure for work activities, avoidance of imposition on others, timely completion of our work duties, etc. This list could go on and on, but is self-evident to those with insight into how practices should work together for the greater good of all.

Our collective (and individual) mantra could be “It’s not about me.” For these kinds of activities, we should not expect participation awards. We should expect to put forth this kind of effort on a regular basis since this is what we originally signed on for.

We will receive metaphorical participation awards, trophies or ribbons when we do our work so well that our peers, referring physicians, administrators, and, particularly, our patients stand up and say “Well done”! These are the kinds of achievements that we should be striving for on a daily basis.

Doing a good job in radiology should be rewarding enough.

No Awards for "Participation" in Radiology

So I’m reading online news last week and come across the 

Breast Biopsies Leave Room for Doubt, Study Finds

”. Just in case any of you missed this leading lay medical journal exposÃ©, the catalyst was also in last week’s JAMA entitled “

Diagnostic Concordance Among Pathologists Interpreting Breast Biopsy Specimens

”. The gist of these articles was that 1) Breast biopsies can be challenging for pathologists, particularly when they encounter features of atypia or atypical ductal hyperplasia; and 2) The recommendation for pathologists to seek a second opinion from colleagues or consider consultation with larger center pathologists when they encounter difficult cases.

I quickly shot a suggestive email to our MD Pathology Director and VP of Marketing encouraging a collaborative campaign to inform not just our patients, but also the entire population of our city and all surrounding communities, that we already routinely do the things that these articles recommend. I waxed…“Our patients need to know that we are state-of-the-art and that they are in good hands and completely safe when they come to our hospital.”

Lest my fervor for a non-radiology specialty get the best of me, I realized that the same passion for radiology should pervade all of us. It is well known that the general public is only vaguely aware of who radiologists are or what we really do. We all need to go on the educational band wagon for our specialty.[[{"type":"media","view_mode":"media_crop","fid":"33564","attributes":{"alt":"Ken Keller, MD","class":"media-image media-image-right","id":"media_crop_7596883296529","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3539","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"Ken Keller, MD","typeof":"foaf:Image"}}]]

Patients need to know that when they saw their doctor in the office, or when they ended up in the Emergency Room or when they followed up with their oncologist after chemotherapy, their pulmonary nodule, their appendicitis, or their cancer remission was diagnosed, in large part, by the radiologist, not their own physician. They need to know the fallacy of their own words when they tell their friends “my doctor found” this or that when, in reality, it was the radiologist that actually made the discovery and then told their physician, who in turn received the credit from the patient. It’s not that radiologists are looking for accolades; on the contrary, we are more than happy to be part of the team. Nonetheless, let’s give credit where credit is due. The radiologist typically finds the lesion and then the treatment flows from there.

We need to capitalize on every chance we get to break our mold of dark reading rooms, quiet personalities, or silent practitioners. We need to sensationalize our life-saving IR procedures and make everyone aware of what a radiologist is and what he or she brings to the table. No other specialty knows the depth or breath of pathophysiology across all patient profiles, regardless of age or sex of the patient.

How do we do this? Volunteer to address issues of concern, perhaps in the local newspaper, or radio or TV spots. Maybe community meetings or letters/appearances to individual patients or patient groups like cancer survivors, support groups, community service groups, etc. As radiologists, there may be a tendency to say nothing when something should be said or to retreat to the comfort of a work station or reading room when an appropriate comment would be timely or on queue. We need to resist the temptation to say nothing and embrace the opportunity to tell the world who we are and what we do.

Our colleagues and profession will be better for it.

Give credit to radiologists when credit is due. 

Tell Them Who We Are and What We Do

I recently reflected on the holiday season and my call duties from a few days ago. After a few linguistic adjustments and with a bit of musical liberty, the following Christmas jingle ran through my mind.

On the first day of Christmas the admin said to me:  “A new contract under your tree.”

On the second day of Christmas the nuc techs said to me: “Two simple scans and a…”

On the third day of Christmas the IRs said to me: “Three central lines, two…”

On the fourth day of Christmas the surgeons said to me: “Four abscesses, three…”

On the fifth day of Christmas the police said to me: “Five gun-shot wounds, four…”

On the sixth day of Christmas the lead tech said to me: “Six new techs this week, five…”

On the seventh day of New Year’s the ER said to me”: “Seven traumas coming, six…”

On the eighth day of New Year’s the nurses said to me: “Eight patients waiting, seven…”[[{"type":"media","view_mode":"media_crop","fid":"30744","attributes":{"alt":"Ken Keller, MD","class":"media-image media-image-right","id":"media_crop_4278502780020","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3226","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right; height: 184px; width: 160px; border-width: 0px; border-style: solid; margin: 1px;","title":"Ken Keller, MD","typeof":"foaf:Image"}}]]

On the ninth day of New Year’s the rad techs said to m: “Nine upper GIs, eight…”

On the tenth day of New Year’s the front desk said to me: “Ten phone calls holding, nine…”

On the eleventh day of New Year’s admitting said to me: “Eleven check-ins pausing, ten…”

On the twelfth day of New Year’s the coders said to me: “Twelve charges pending, eleven…”

Let’s all decide to make next year better.

The 12 days of Christmas, radiology style.

12 Radiology Days of Christmas and New Years

Over the years I have (tongue-in-cheek) reminded my clinical colleagues that radiologists are the smartest doctors in the institution because of our requisite knowledge of all kinds of pathophysiology, not just the lesion itself, but also how and in whom it presents. Doesn’t matter if it’s a fetus, neonate, infant, child, teen, adult, or the elderly. Doesn’t matter if it’s a male or female. Doesn’t matter if it’s the foot, thigh, abdomen, chest, head, or neck. For many radiologists across the country, we are just expected to know and generally we do. Few physicians have the breadth of knowledge we need to effectively function on a daily basis. So I like to remind my friendly colleagues of that whenever I can, all in good-natured fun. Unexpectedly this proclamation came back to me this past week in an interesting idea exchange.

We’d had a case of primary pulmonary and pleural tuberculosis evade diagnosis for weeks, despite multiple hospitalizations and many different physicians, including family medicine residents and program director, hospitalists, and infectious disease. Initially, there was a garden-variety RLL consolidative pneumonia in a 26-year-old male. Then the typical “lost to follow up” period for six months and then resurfacing with ipsilateral persistent pneumonia, single rib fracture, small pleural effusion, and pneumothorax after a fall. Findings were thought to be post-traumatic, but the persistent pneumonia was revealed after lung re-expansion. Three blood cultures were positive for Staph aureus, thought to explain subsequent cavitation two weeks later. Interval CT showed empyema, subsequently drained and cultured, also with S. aureus results. Patient finally improved on IV antibiotics and was eventually discharged.

Patient returned after his meds ran out and repeat CXR showed persistent or worsening pneumonia. Repeat cultures again showed S. aureus. CT showed increasing parietal and visceral pleural thickening, now with hydropneumothorax. Another chest tube placed, but now someone finally considered the possibility of TB, so AFB staining was done and thankfully the final diagnosis was forthcoming.[[{"type":"media","view_mode":"media_crop","fid":"29724","attributes":{"alt":"Ken Keller, MD","class":"media-image media-image-right","id":"media_crop_3165135785173","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3098","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 184px; width: 160px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":" ","typeof":"foaf:Image"}}]]

So, now fast-forward to the CPC presentation a few weeks ago, fully three months after the diagnosis had been made with the patient finally making meaningful clinical improvement. The second-year resident is presenting the case in detail to all the medical students and other residents, as well as a few attending physicians who decided to drop in for the luncheon discussion. I dovetail in discussion of the imaging findings at the appropriate time during the overall presentation. Then there were lots of questions about how could the diagnosis have been made sooner, why wasn’t the ID department clued into TB sooner, was the S. aureus just a contaminant or was there co-existing Staph and TB pneumonia, clinical and imaging differences between primary and reactivation TB, etc.

Finally one of the more senior attendees whom I’ve known for 25 years says to me “Doctor, why didn’t radiology suggest this was TB from the outset? I thought you guys knew everything about everything?” The entire audience chuckles as I scramble for a response. I deadpanned, “Would you like us to suggest TB on every consolidative pneumonia we see? Imagine the firestorm that would follow. We all need to have a higher index of suspicion, particularly the docs taking care of the patient, since they know the history and specifics of the case. Radiology can’t save the day every time.”

He smiled with his one-word response “TouchÃ©.”

Radiology can’t be expected to save the day every time.

The All-knowing All-seeing Radiologist

Ah, the aura of being (like) a doctor. Respect. Notoriety. Admiration. Who isn’t intrigued by it? Who doesn’t want to know a doctor or be near one? Who doesn’t secretly desire to be one? Ben Casey. Dr. Kildare. Marcus Welby, MD. Hawkeye Pierce. Who wouldn’t enjoy passing through doors open to them but blocked to others. St. Elsewhere. ER. House. Grey’s Anatomy. And so on. And while this shouldn’t be particularly surprising, like everything in life, there are situations where some take advantage of a situation for their gain while others choose a different path.

Because of my IR background, I recently experienced a very interesting situation. We had a morning liver chemoembolization case for metastatic colon carcinoma and were hosting an industry representative since we were trialing a new catheter. As usual, the rep arrived in forest green surgical scrubs. They were not the administration’s approved color, but oh well. The case went fine. All were pleased with the outcome. Case was over, electronic “paperwork” completed and everyone went about their business, onto the next case. Then Tumor Board over lunch. Great cases, including an angiosarcoma and breast carcinoma in a BRCA positive 34-year-old woman.

Afternoon cases included a repeat biopsy of a 2.5 cm complex thyroid lesion. Prior FNA suggested carcinoma, but was inconclusive with a repeat biopsy suggested. Seemed simple enough. Coags were normal, so we made plans for a definitive core needle biopsy.

I had previously agreed to trial a new needle, but was surprised when the needle rep arrived to witness or assist during the biopsy. I mentally smiled and dismissed his “vendor vigor.” As I gathered paperwork for the obligatory “time-out,” I briefly pondered the rep’s navy blue scrubs and silently reflected on the trichotomy of green vs. blue vs. approved brown.  The case went well, no complications, patient left the department in good condition and as I completed my post-procedure note, I dismissed the thought of ever revisiting the cast of characters or circumstances of the morning embolization or afternoon biopsy cases. I was already anticipating wrapping up all daily activities since I was flying out that evening.

A few hours later while waiting in the TSA security line I began visiting with a sharply dressed young women who initiated the conversation by telling me she thought she would be late for her flight since she had to change out of her scrubs back into her business suit to catch her flight home. Turns out she also was an industry rep for a new laparoscopic laser that was trialed earlier that day in OR. We spoke very briefly, but I was impressed with her professionalism.[[{"type":"media","view_mode":"media_crop","fid":"27304","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_2658643184534","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2630","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 173px; width: 150px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":" ","typeof":"foaf:Image"}}]]

To my chagrin, after clearing security and picking up a newspaper, I arrived at the gate area and noticed all three reps seated in different sections, all waiting to board the same flight. Two were still wearing the same scrubs I’d seen earlier in the day. Then I really started to wonder. How many airports, airplanes, boarding gates, bathrooms, restaurants, hallways, etc. had these scrubs seen before they entered the procedure rooms earlier that day? How many contagions, bacteria, viruses or other undesirables might they be transporting?

It got me to thinking about avoiding complacency and remaining vigilant in all areas of our workplace. We do a good job of focusing on maintaining our interpretative edge, consulting and performing procedures, but it’s not enough to examine just ourselves, our techs or nurses. We need to constantly scrutinize everyone that enters our department if we want the best outcomes all the time. Our patients deserve no less.

Who wears the scrubs in a medical relationship?

Scrutinizing the Scrub Scam

OK, so my undergraduate pre-med major might not have been the strongest choice, especially if I had not been accepted into medical school. My advisor said he thought I was strong enough to get in, so it didn’t really matter what my major was. He said it could be psychology or history or even music. Since I was a bit more driven toward science, but didn’t particularly like chemistry, I chose zoology which I thought was reasonably close to the human body. After all, I wanted to be a doctor and we dissected a pig in high school physiology, right? At least that was my 18-year-old thought process.

It seemed to work well enough. Got through med school OK. Onto diagnostic radiology residency. Emerged intact. Then the boards. Psychologically traumatic - maybe I should have chosen psych. After months of work and study, I passed unscathed. Then I began my career, finally doing (and enjoying) what I’d dreamed of, what I trained for and what made it worthwhile going to work everyday.

Now fast forward through the decades heralding the introduction, and now ubiquitous utilization, of MRI. The maturation and expansion of IR. DRGs thrust upon us. Federal mandates. Reduction in legislation. Denials. Obama’s ACA. Ah yes, the professional challenges we face on a daily basis certainly makes life interesting. Makes any radiologist worth their salt want to come to work everyday and make a difference. These challenges have kept me (and thousands of others) going all these years. It’s also what makes so many young, eager and intelligent minds seek out radiology, clearly the premier, most satisfying and most cerebral specialty in all of medicine.

So now back to daily duties. I’m reading on-call, over-night studies from the ER. We are immersed in an unprecedented oil boom in the Bakken Shale. It’s like nothing any of us have ever seen or could even conceptualize. Just like the ‘49 gold rush in California or the ‘98 Klondike in Alaska. The only thing is, these (oil) miners don’t ride horses or mules. Yes, liquor still flows freely. Yes, things can get out of control. Yes, there may not be enough law enforcement at every corner to keep order everywhere all the time. But these folks  drive huge fully loaded pick-up trucks or 18-wheelers hauling oil, water, dirt or machinery.

The next exam on my work list is a femur and lower leg X-ray. How hard can that be? A piece of cake compared to an abdomen/pelvis CT for nonspecific pain, right? I check the history. Then I double check the history. Reason for exam reads… “Run over by own vehicle.” That doesn’t make sense to me so I call the ER to inquire. Since the images are time-stamped at 0300 and I’m reviewing the study at 0855, it’s been less than 6 hours and yet everyone in the ER knows the story, even though they weren’t on duty when it occurred.

An “oily” as the common vernacular characterizes a new age oil-field worker had experienced a few too many encounters with ETOH. He managed to drive, though not control, his vehicle through some of the streets of our boom-town. Inexplicably, the door of his vehicle opened while moving and he fell out of the vehicle. Incredibly, he managed to actually fall “under” the vehicle which then ran over him. Not to be outdone, he then somehow managed to overtake the vehicle and get back into the driver’s seat, regain “control” and continue driving down the road. There was enough of a neighborhood ruckus that law enforcement soon arrived and eventually apprehended the driver, destined for the ER. Lest anyone consider this fiction, the story made the 

From time to time, when our workplace gets chaotic, many of us have said we work in a “zoo.” I voiced that same euphemism as I laughed about his case with my colleagues. Then I wondered…

Was it anything like what I expected when I studied zoology, or was it more like zoo-radiology?

The radiology field can be a hectic one, an environment we affectionately refer to as a “zoo.”

Zoology or Zoo-Radiology?

I’m sitting in Thursday’s Tumor Board and the new radiation oncologist is waxing eloquent about radiosurgery, gamma knife, cyberknife and fractionated external beam radiation. He projects an MRI image of a T1-weighted contrast enhancing parietal lobe mass and then launches into a soliloquy about his treatment plan based on the volume of this metastatic lesion, hoping to spare the speech center. He then challenges the audience by asking “Does anyone know how to calculate the volume of a sphere?” I survey the room for the fourth year medical students thinking they are closer to geometry than anyone else, but they are mute. The other physicians in the room are silent. Perhaps they thought it was golden. Then I recall past drainage procedures and my own IR geometry kicks in. Since no-one was answering, from the cheap seats I blurt out “4/3 pi r cubed.” The oncologist chuckles, acknowledges the correct answer and proceeds with his discussion. OK, end of the cute story, right? I thought so, but then my interest is piqued in the next few days when serendipity connects two seemingly unrelated events.

It’s Monday morning, just four days after Tumor Board and I’m discussing a peer review case with a colleague. I remind him that when we render an opinion different from the prospective reader, we need to take some sort of action to address the discordance; perhaps an addendum, perhaps a phone call. Something needs to be done to make sure our clinical colleagues realize what is happening.

The patient has to be properly taken care of and not slip through the cracks. “I know, I know,” is the standard reply. “Keep reminding me until I get it into my pea-sized brain.” Of course it was just a quip made in jest. No big deal. I just laughed and said “Well then drink a bunch of water and maybe it will swell to the size of a grape.” We both laughed and then the conversation was over. End of story, I thought. Not so much.

Fast forward to the following Thursday, now just a week following the previous Tumor Board. Now I get an e-mail from our respected neonatologist who writes “…I've been meaning to ask you about this for some time, and it keeps falling out of my pea brain.”  Since she is a great colleague and since we serve together on committees, I figure I can have a little fun. I replied with a carefully crafted e-mail response that may have universal application.

I explained that she was my second colleague in the past week that said they had a pea-sized brain. I told her “…Just drink a bunch of water and because of Brownian motion, your brain will swell to the size of a grape. Assuming the average pea is 5 mm in diameter and the average grape is 16 mm in diameter, that will increase the volume of your brain more than three times. Imagine that. All from just drinking water. Come to think of it, since we are talking about grapes, perhaps it would be even better if we were drinking wine.”

So I got to thinking. Maybe we should all be drinking wine occasionally. The literature and evidence-based guidelines would support this recommendation.

The expression “pea-sized brain” gets a new twist. 

Grow Your Pea-Sized Brain

 deserves consideration and appropriate responses. American women deserve no less as they make decisions about their breast screenings and overall health care.

The medical professional response is quite detailed and necessarily scientific. However, it clearly exposes the shortcomings and flaws of a rationale suggesting that screening mammography in women 40 to 50 years of age should be questioned or even suspended.

In the past two decades, there have been a number of well designed, randomized and controlled clinical trials that clearly indicate that women in their 40s who were screened with mammography had a 15 percent reduced risk of dying from breast cancer compared to women that were not screened. The mortality reduction increases to 20 percent for women in their 50s.

Some would argue the reduction is even greater, but suffice it to say, there are clearly proven unquestionable benefits to screening mammography. The American Cancer Society recognizes this benefit and recommends yearly screening mammography after age 40, as has been the official recommendation for many years.

On the other hand, the recent story focuses on the scientifically flawed Canadian National Breast Screening Study (CNBSS) which forms the basis for the equally flawed recommendations of the United States Preventive Services Task Force (USPSTF) that women in their 40s not receive the benefits of annual screening mammography. The CNBSS was released more than two decades ago and if nothing else, is severely outdated.

However, close scrutiny of the study indicates several violations of scientific study, rendering it useless to those who seriously consider data that can shape broad policy regarding recommendations for women across America. Obviously any organization or agency can choose to ignore scientific evidence-based studies to formulate their own self-serving recommendations. The informed consumer of healthcare services will see through this shallow posturing and specious argument.

Several things render the CNBSS study - and therefore the USPSTF recommendations - useless.

1. The study was released more than 20 years ago, so the current recommendations are based on poor quality mammography that used second-hand machines, which were not state-of-the-art at the time of the trial.

2. Present day mammography techniques use grids which reduce scatter radiation and improve resolution and image clarity making cancers easier to see on mammograms. Most of the mammograms used in the Canadian trial did not use grids.

3. The CNBSS mammogram technologists were not taught proper positioning techniques for performing mammograms nor did the radiologists have special training in mammogram interpretation. Current technologists are certified in mammographic positioning and current radiology residency training programs devote months of training to interpret mammograms.

4. Women were not properly selected or randomized for the trial. They were physically examined first and women with palpable breast masses (that could be felt) were more often “randomized” to the mammography group. Women without a mass were more often sent to the “control” group. It is no wonder that the mammography group showed more cancers; these women likely had cancer before they were ever enrolled in the trail. Obviously this group would have a higher mortality rate. The USPSTF chose to ignore this scientific data since it would invalidate their recommendation.

5. Current US mammogram centers must be accredited to pass the Mammography Quality Standards Act (MQSA) federal inspection standards to permit payment for their services. It is almost certain that the majority of the centers used for the Canadian trial would fail current MQSA inspection and not be allowed to perform mammograms, let alone form the basis for a far-reaching recommendation suggesting that women in their 40s should consider not getting mammography.

The common sense approach is not scientifically detailed, but perhaps is more understandable by the majority of readers who depend on their medical providers for sound advice.

It is a well-understood axiom that regardless of the issue, it is better to identify a problem when it is small and more manageable than when it gets larger and becomes more difficult to handle. Indeed, if left too long, it may be impossible to fix.

I would offer two every-day examples that everyone can easily understand.

1. The On-Star service currently installed in many GM vehicles will send a periodic email to the customer, equivalent to a screening mammogram. This “screening” email will tell the customer many things about the current condition of the vehicle, much like a screening mammogram tells the woman about the state of her breast health.

For this example, let’s focus on the tire air pressure readings. If the pressure in one tire is low, it will be colored yellow or red indicating an issue that the customer should address. He may choose to ignore the warning and run the risk of ending up with a flat tire or getting in an accident, but more likely he will take action and get it fixed. The customer (or woman) knows that the On-Star screening service (mammogram) they have received is designed to identify a small tire problem (or breast issue) in its earliest stages when it can be more effectively taken care of or cured.

Few of us would ignore a warning that our tire is going flat because we don’t want to deal with a catastrophe down the road. Similarly, why would we ever choose to avoid screening mammography when it could save our life through earlier detection of a cancer?

2. We are all cognizant of identity theft and most of us have heard of agencies, or even our credit card companies, that “screen” or monitor our credit and the use of our credit cards. Most of us get periodic notifications from them when our credit card balance increases by some specific amount, when our credit report has been accessed by some organization or when there has been unusual activity in our account. Most of us would take these “screenings” seriously since we want to avoid the catastrophe of identity theft. We watch things carefully so we can identify any irregularity very early on and catch any problem early when it can be effectively handled before it’s too late.

None of us would ignore a notification or “screening alert” telling us that there was unknown activity in our credit account. Similarly, why would we ever choose to avoid screening mammography when it could prevent the catastrophe of dying from breast cancer?

It is so obvious and yet it still bears repeating. Mammography is still the best defense we have against breast cancer. We have all been touched by women who have had breast cancer. It is clear that a 42-year-old woman who has a screening mammogram that detects a breast cancer the size of a pea has a whole lot better chance of surviving than a 50-year-old women who is diagnosed with a golf-ball sized cancer at her first mammogram since she waited to be screened because of what she read in the news or because she followed the USPSTF guidelines.

Bottom line: Don’t do what the US task force recommends. Do what the American Cancer Society and knowledgeable medical societies recommend. Begin annual screening mammograms at age 40. This recommendation is scientifically based and has not changed for decades. It will save lives.

The CNBSS and the USPSTF mammography recommendations are useless, and women in their 40s should be screened. Here’s why.