Laurence Spitzer, MD

In my now 15 years of being a radiologist, I have had the fortune/misfortune of being involved in two hospital takeovers. Not sure how that ranks in terms of other radiologists, but I can say that speaking from experience, the two transitions have been radically different.

There will always be that air of uncertainty amongst the medical staff and hospital employees as to what the new hospital or hospital system will bring. Will things be better when the new hospital or healthcare system take over? Will things be worse? Will my job change? Will I lose my job? Often the powers that be will start to send out information, usually via e-mail with the same politically correct, administrative rhetoric such as “All employees of Hospital X who are in good standing, can be assured that they will maintain their current position when Hospital Y takes over.” That’s all fine and dandy unless you’re the low man on the totem pole at work, and your boss tells you that he or she’s been told that everyone’s expendable. All of this creates a great deal of stress and angst.

As all of us with a little grey in our hair know, change can come in many different forms. Noticeable changes that are positive could mean upgrades to equipment, deeper staffing, improvement in benefits, or increase in salary. Other less impactful positive changes might include more time off, better food in the cafeteria, or even a better parking spot closer to the hospital entrance. All of these changes could of course go the opposite way, and as a result have a negative impact.

The first hospital takeover I was subjected to was of a very formal nature. It was meticulously planned, and calculated to the exact minute. We would be closing the doors on an old, physically deteriorating building that had existed for over 100 years and would be moving into a state of the art, breathtakingly beautiful $300 million facility. I will never forget the actual day of the move when the remaining 15 or so patients were put into ambulances and driven to the new hospital, while the doors of the hospital that I had spent the first 12 years of my career were padlocked shut, and the lights turned off. It was a very sad moment for me.

Meanwhile, the new hospital was opened, the lights were turned on, the CT scanners revved up, and we were open for business. Yours truly was selected to be on call the very first night, and I will never forget being the first radiologist to dictate an ankle X-ray as the first imaging study performed at the new hospital. Was I nervous? Absolutely. So much so that I blew right through a fracture of the calcaneous, before I recognized that I had overlooked it. Right away, change was evident. It was amazing to have brand new equipment that worked, doors that didn’t squeak, 5-star food in the cafeteria, spit shine floors and walls without scuff marks from stretchers banging in to them, comfortable chairs at my workstation, and even toilet paper in every bathroom!

Hospital staff smiled, security guards said hello to you, administrators walked the halls in a state of utopia, and patients were thrilled to be admitted to rooms that were all private, and had 42-inch flat screen TV’s in them. Things couldn’t have been better.

To contrast that, the second hospital takeover has been something of a totally different experience. Not necessarily for the worse; just different. This one occurred over a weekend, so from the get go; there was less hype and certainly less presence of the change, as it happened on a Saturday. The hospital was actually not closing as in the first situation, but had merely been sold to a new healthcare system. As in the first takeover, the months and days leading up to the takeover were filled with nervousness and anxiety amongst the staff members, as there had been little to no communication from the new hospital system as to what to expect.

All we were told was, “Wait until October 2, and then we can tell you everything and we will share everything with you, in terms of what to expect.” OK, fine, I could wait until October 2. I knew that my job was secure, I knew that I wasn’t going to be moving anywhere, and my experience had instilled in me that things wouldn’t be that much different. Well, guess what? Its now October 20, and I haven’t seen one measurable change since the new hospital took over. My parking spot is the same, my computer tinkers along and still crashes once or twice every day; the food in the cafeteria is the same. Even my ID badge still says the old hospital name on it. Oh wait a minute, check that. I did attend a banner roll out, on the hospital front lawn where they unfurled a 15-foot banner with the new hospital name on it, and they gave out free hand sanitizer and Chap Stick to all that attended. I guess it could have been worse. You know what they say; “A change would do you good.”

Articles

A tale of two hospital takeovers from a radiologist who lived through them.

A Change Would Do You Good

Just in case you have been living under a proverbial rock the past few weeks, you may have neglected to notice that a good portion of the Eastern seaboard which accounts for about 20% of the U.S. population, just withstood a major winter storm. Snowfall totals included: Washington D.C.: 28 inches; Philadelphia: 23 inches; and New York City: 27 inches. According to weather service records it was either the third or fourth biggest snowstorm, since records were kept.

The brunt of the storm struck on a Saturday, and (thank God!), I wasn’t on call. If I had been, there would have been no way I would have been able to drive in the near total whiteout that was happening during the day on Saturday, and therefore I would have been sleeping on a gurney in one of the ultrasound exam rooms in the hospital. Nevertheless, my first day back to work was Monday, following the massive snow dump. As I began to go through the caseload from the weekend, I came upon a routine X-ray of the left hand request from the ER. The history stated: “snow blower accident.” As one could guess, before even looking at the study, there were traumatic amputations of the distal second, third, and fourth digits.

I shuddered as I went about dictating the case, imagining how the accident might have happened: “hmmm clogged snow blower, let me shut it down, and then I can stick my hand in the intake and unclog it…AARRRGGHHH!!” Well, maybe the person didn’t exactly use that exact expletive, but you get the point. I felt very lucky, as it was only a couple days ago that I borrowed my neighbor’s snow blower (which I had never used before), to clear the 23 inches of snow from my driveway.[[{"type":"media","view_mode":"media_crop","fid":"45519","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_9436100804870","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5215","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: 181px; width: 200px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Â©bilha golan/Shutterstock.com","typeof":"foaf:Image"}}]]

I finished dictating the case and began to think of all the seasonal-type injuries that we, as radiologists, are accustomed to seeing. As I mentioned, during the winter, besides seeing amputated fingers from snow blower accidents, you see a fair share of fractured ankles from ice skating, skiing, and snowboarding. Nuclear cardiac stress tests for the invariable “chest pain while shoveling snow;” MRI’s with ACL tears from skiing, and the innumerable fractured hips, elbows, wrists, and ankles from “slipped and fell on ice.”

Assuming you survive the numerous hazards of winter, the coming of spring and the warm weather brings a whole other host of outdoor related injuries to the EDs of hospitals. We have all seen the “hit in the orbit with a baseball” and the Achilles tendinopathy from “overuse running injury.” What about the fractured pelvis from “horseback riding injury,” or the dislocated shoulder from the overzealous weekend mountain biker?

Ultimately, summer comes; my favorite time of the year. Being cooped up inside for months, children emerge from school classrooms and adults awaken from winter hibernation. It’s time to go to the shore for the weekends! But, don’t go diving head first in the shallow water, or you might end up with a cervical spine fracture, requiring a MRI. Or, what about the subdural hemorrhage the 75-year-old man sustains from “fall from ladder while fixing the roof.” How about the severed forefoot seen on a foot X-ray from the drunken guy with a chief complaint of, “lawnmower accident while wearing flip flops?” This pales in comparison to the MRI elbow for “golfer’s elbow.”

Reading all of these different seasonal related injuries, one would think that the practice of radiology has worked out some sort of deal with mother nature, in order for her to continuously supply us with imaging studies to interpret. So, the next time it snows, and I sure hope we are done for the season, and you are at work reading cases, and you come upon that lumbar spine X-ray request that says, “slipped and fell on ice; back pain.” Think to yourself, it’s that time of the year again!

It’s That Time of Year

Roughly 15 years ago when I decided to pursue a career in radiology, I had a fairly good idea of what to look forward to. From what I had seen in medical school, to doing rotations in the hospital, to speaking with attending physicians, I felt confident that I would be getting into a field that was really interesting, constantly changing, and always seemed to be at the epicenter of patient care, while at the same time providing a comfortable financial life, in a low stress environment.

After finishing residency and fellowship, I joined a small group at a local community hospital. This was during the time of the “soft” job market when there were plenty of jobs, and not enough radiologists. It wasn’t uncommon back then for me to get about five to six e-mails every week describing practice opportunities that offered $500k starting salaries, offers to fly me in a private jet (no joke) to places like Ketchum, Idaho for an interview, and other offers from groups offering $10k to cover moving expenses. Whether these carrots on a stick were actually truthful or not, who knows, but certainly times were different back then.

The decade from 2000–2010 was great, and I loved my job and the practice that I was in. I really had my mojo going! The diversity of cases kept me interested, the people I worked with were happy and glad to come to work every day, and our department was always one of the highest revenue generating departments in the hospital; year in and year out. From a financial perspective, I still couldn’t believe it when I saw my paycheck every month, after living on a resident/fellow salary of $45k per year. Every day, it seemed like there was something new to learn, and the field seemed to be growing exponentially with the development of 64 detector, then 128 and 256 detector CT, cardiac CT, PET/CT, newer applications for MRI, the increased utilization of ultrasound, and on and on.[[{"type":"media","view_mode":"media_crop","fid":"41656","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_1965549669989","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4423","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: 180px; width: 200px; float: right;","title":"Â©Sign N Symbol Production/Shutterstock.com","typeof":"foaf:Image"}}]]

My passion for radiology and being constantly active spilled over into other areas as well, and I was active in hospital politics, teaching residents, writing articles for journals, and participating in radiology advocacy and leadership at the local and regional level.

Then there was a gradual change for the worse. Our hospital and its governance came to the realization that, financially, it couldn’t exist as a stand-alone hospital in the volatile health care market, and it eventually succumbed to the takeover by a large health care network. Our hospital closed and we (literally speaking, as the last few patients were transported by ambulance!) moved to the next town to set up shop in a newly constructed, state-of-the-art tertiary care center.

We soon realized that our previous model of autonomy, independence, and happy atmosphere was quickly extinguished. Practicing radiology became very corporate and regimented, and it seemed like every day we were given another rule or mandate to follow. We not only lost vacation time, experienced a salary cut, lost our half day off per week, and the ability to make our own call schedule, but our work hours increased, our call increased, we were charged with driving to outpatient facilities, and our caseload increased significantly. All for the benefit of the “network”, with no doctor appreciation on the back end.

Right before my eyes, before I could read the writing on the wall, my mojo had been taken from me! And it wasn’t just confined to the radiologists. Technologist morale took a nosedive. I would often hear them arguing, back stabbing, and finger pointing at one another when something went wrong, rather than before, when they would all help each other out. This corporate culture of “my way or the highway” spread to other physicians as well, with many dedicated, competent, and well-respected physicians from our former hospital, either flat out quitting, being forced into early retirement, or being fired.

I was desperate, frustrated and depressed. How could things have taken such a turn for the worse? What happened to my passion for radiology? Every day, I felt bored, un-motivated and a lot like Fred Flintstone at the stone quarry; just going through the motions. To exacerbate things, while the decade was coming to a close, the job market had turned polar opposite. Jobs were now scarce, good radiology residents graduating from solid programs couldn’t find jobs and were being forced to either do a second fellowship or accept job offers in undesirable locations or for significantly less money. I was looking at the distinct possibility of having to move my family, doing locums work, or (egad!) leaving radiology altogether to work in industry.

I poured over all the job market websites; I dug deep into my contact list to ask around for possible opportunities, I asked for favors from former associates. No stone was left unturned. There was one glimmer of hope, though. I had a friend who was the director of a small group at a tiny hospital for whom I had done some moonlighting for, earlier in my career. We had managed to keep in touch and I had always had a great deal of respect for her. Her group was also undergoing some changes and although she wasn’t quite ready to commit to offering me a job, I continued to keep in touch with her, and basically kept nagging her. Deep down inside, I knew something would break. Sure enough, she thresholded over, and the offer came.

Although the salary is less, and the commute to work is longer, I definitely made the right choice. I am back to loving my job, I enjoy working with the staff, and even more importantly the leadership has respect for my opinions, and for me as a physician, rather than a mere laborer. I am reading the modalities that I enjoy reading, doing procedures that I am interested in, and have re-discovered my passion for radiology. To sum things up; my mojo is back!

Experiencing the transitions in the field of radiology has made for many ups and downs.

How I Got My Mojo Back

As work volume has increased and radiologists are burdened with reading more cases that get more complicated as patients live longer and, therefore, develop more medical issues, there seems to be less and less time to reach out to our colleagues to discuss interesting cases. Further leading to this decrease in physician-to-referring-physician contact is the omnipresence of PACS.

Work stations are now located in most of the nursing stations, ICUs, physician lounges, and many outpatient physician offices. Gone are the days when the surgeon would stop in the radiologist’s office to review a CT exam prior to operating on a patient. It’s been years since I can recall when a pulmonologist or urologist would meet me in the consultation room to review a CT chest or a renal ultrasound, just before heading off to the bronchoscopy suite or OR. Why bother with the radiologist, when I can just pull up the case on my monitor, or tablet, or even my iPhone and see where the tumor is or where the pulmonary nodule is that I need to biopsy?

In light of these recent changes to the field of radiology, some genius came up with the innovative idea of having critical values instantaneously sent to the referring physician. In theory, this idea would seem to have many advantages. First, it would avoid the legal issues of documenting that a critical value in a radiology exam was reported to and received by the ordering physician. We all know that one of the main reasons that radiologists get sued is because of lack of communication and lack of documentation of communication.

Second, by ranking these critical values into a level of priority, such as significant, emergent, or significant-document only (because I only want to document it in the report-not bother the referring physician), one can prioritize certain imaging findings, so that they get acted upon in an appropriate and timely manner.

Finally, the documentation gets embedded in the dictation and the patient’s legal medical record, with a date, time, and name of the health care worker that was notified of the finding.[[{"type":"media","view_mode":"media_crop","fid":"37703","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_4345636521131","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3732","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: 107px; width: 160px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Â©Gajus/Shutterstock.com","typeof":"foaf:Image"}}]]

When I first was introduced to one of these critical value-reporting systems, I must admit I was quite skeptical. Call me old school, but very few things in radiology are more gratifying than hearing a close physician friend who just sent in his patient for a CT of the chest, say to you, “I really appreciate you taking the time to call me to tell me that Mrs. Jones has a lung cancer on her chest CT. I will call her right now, and get her in for a biopsy. Thank you for the call.” Nevertheless I began to use it, and found out very quickly that some of my initial doubts were proven to be true.

It was only after using the system for a short while, that I found out that, A) it doesn’t work after 5 PM, B) it doesn’t work on weekends, C) it doesn’t work for the emergency department, and D) it takes many months for the majority of referring doctors to register with the system, and the system needs to be constantly updated and refreshed for every new doctor. Not being told these facts before using the system, I recall reading a CT of the abdomen late one Friday that demonstrated hydronephrosis of the kidney secondary to a distal ureteral stone. Not knowing that they system did not function on the weekend, I used it to notify the urologist. Little did I know that he wouldn’t receive the message until Monday morning.

One of the more annoying faults of the system is that it doesn’t work for the emergency department, which just so happens to be one of the biggest referral sources for all imaging in the hospital. In summary, after learning from these mistakes and the shortcomings of this new technology, I only use the system to document that I spoke to a referring physician, after I go old school and call them on the phone. After all, like I said before, few things are more rewarding during a busy day, than five simple words, “Thank you for the call.”

Longing for the days when physicians called each other. 

Thank You for the Call

Just recently, I received my certificate from the American Board of Radiology designating me a Diplomat of the ABR for having fulfilled the requirements of maintenance of certification (MOC). This certificate was given to me for successfully passing the 10-year recertification exam, given in Chicago, this past March. As I stared at the document, and read all the official language on this quite sophisticated looking diploma, which ironically looks no different than the one I received 10 years ago, after having passed the “original” 10 part oral board exam, I began to reflect back on that dreadful event…the oral boards!

I can vividly recall being a fourth-year radiology resident, and each day, starting around the beginning of April, of our fourth and final year of residency, we would cut out early from our assigned rotations, and head to the library to study for the oral boards. Since our program was a small size residency program, there were only three fourth-year residents. I can only assume that this was the reason we were allowed to leave early each day, as the workload could be handled by the other residents and attending radiologists (such a thing would be considered blasphemy today). In any event, the three of us would sit down and go over “hand-me-down” questions that were given to us by previous fourth-year residents, who had already graduated and sat for the boards. We would simulate what it might be like to be in Louisville, being asked to produce differential diagnoses based upon one or two images. Back then; many of us still used textbooks, review books, and many other 

 sources of radiology manuals, instead of the Internet. We even went as far, as to see who could accumulate the greatest number of books by the time they graduated. As if the greatest number of books translated into being the smartest radiologist or something. Now, it almost seems archaic for one to refer to a textbook

 as opposed to just pulling it up on the Internet, when you have to look something up. How strange.[[{"type":"media","view_mode":"media_crop","fid":"28587","attributes":{"alt":"Laurence Spitzer","class":"media-image media-image-right","id":"media_crop_1472815082930","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2914","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: 221px; width: 166px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":" ","typeof":"foaf:Image"}}]]

Ultimately, the end of the year came, and it was time for us to head down to beautiful Louisville, KY, as so many generations of radiology residents had done before us, to sit for the dreaded oral board exam. I can recall the musty, dark, old hotel room with the faux wood furniture, and the stained bed linens. I can recall seeing other residents in the hallways and hotel lobby, biting their nails, pacing back and forth, huddled in study groups for some last minute cramming. It’s amazing with all the tension and nerves that I didn’t just call it quits and leave, right there on the spot.

Finally, it came time for me to be examined. Although, I don’t remember exactly what I was asked in each section, I do remember certain things: like the examiner who crinkled a cellophane candy wrapper while I was testing, and then proceeded to get up and walk back and forth as I was answering his questions. Or the examiner that showed me a very strange looking bone tumor in an MRI of the femur, and then cut me off mid-sentence when I was describing the tumor, by saying, “forget this question, you’ll never see a single case of this in your entire career! You passed!” As everyone before me had warned, the day was extremely stressful, tiring, and nerve wracking. All I could think of during the flight home was, “there has to be a better method to evaluate ones fund of knowledge and level of competence after finishing a radiology residency.” I was genuinely amazed to open the letter from the ABR a couple weeks later to find that I had passed the exam.

Jump ahead 10 years later, and all those horrible memories came flooding back to me when I received the notice that as part of the ABR’ s MOC program, I would be required to sit for a recertification exam in three subjects of my choice. Wow, it really does never end

 No matter how old you get, and how long you’ve been in practice, there’s always a test (and a fee!) at the end!

Although, the format would be different, I kept thinking to myself, how in the world am I going to find the time to study for a board exam when I am working 9-10 hours a day, taking call once a week, staying in the hospital until 10 pm at night, coming home to a family with children with homework, after-school activities, bills to pay, chores to do around the house, etc. Impossible! How would I succeed without having people to ask who took the exam before me? How would I succeed without the resources that I had as a resident? How would I find the time to study?

Ultimately, I found one colleague who had taken the exam (as I was only the second year of the test being administered), and ironically he tested in two of the same sections that I had elected to be tested in. Despite being exhausted from work each day, I tried to review sample cases each night for about 15-20 minutes, utilizing the Web to find as many radiology cases as I could. Funny how this time around, I did almost all of my studying on the Internet, rather than with books.

Finally, the day came. I flew to Chicago the day before, and stayed overnight at a local hotel (no, not the Executive West like in Louisville). On the morning of the exam, we were all taken by bus to the ABR testing site. After checking our IDs, we were led into this enormous, dark testing room, filled with about 500 mini workstations in a single-file line. We were assigned a small workstation, within a little cubicle, and the test began. Some four hours later, it was done. I had finished. Again, I had this strong sense that I would be coming back to Chicago, as I felt for sure that I had failed. Surely, I thought, there must be a better way to do this. There were many questions I had no clue as to what the answer was, and it felt like there were many cases that I had not only never seen during my preparation, nor had I ever come across in my practice. On top of this, there was a healthy selection of non-clinical questions pertaining to health care, statistics, probability, and other really “relevant” information.

Several weeks later, as was the case 10 years before, I almost had a heart attack when I received the letter from the ABR stating that I had passed the exam! Are you kidding me? Me? Passed on the first try? Today, as I stare at the diploma, I can only think to myself, it’s more than likely I will have to do this again, 10 years from now. As before, you have to ask yourself one question: does it ever end?

The nerves and tension of radiology certification exams are an unwelcome reoccurrence. 

Radiology Certification: Does it Ever End?

A very strange thought occurred to me the other day while at work, and it made me stop right in the middle of what I was doing and caused me to reflect for a moment. I was reading ultrasounds that day, and one of the technologists came in to the reading room to go over a case that she had just completed.

The order was for an ultrasound of the scrotum, and as I was listening to the tech tell me the patient’s symptoms, and what the referring physician’s request said. She told me that the patient did not speak English, but that he came with a family member who did speak English, and had offered to interpret. I thought to myself, that’s convenient. Now, at least we can get some additional history, and maybe even find out where the patient is feeling discomfort, or what is bothering him.  The tech went on to tell me that the patient was a 50-year-old man with right sided testicular pain. Fair enough I said, as I asked the tech what she saw, and proceeded to bring up the case on PACS. She then told me that the family member who did the interpreting for the patient was, in fact, the patient’s 14-year-old daughter, and that she had insisted on being in the room during the exam. It was at this point that I dropped what I was doing, pulled my eyes away from the monitor, and said to the tech, “What?” She said, yes the patient’s 14-year-old daughter (and the father) had insisted on her being present during her father’s scrotal ultrasound exam.

As I reflected on the situation and thought about how I would feel, and how strange and uncomfortable it would be for my own daughter to watch me have a scrotal ultrasound, I imagined that maybe the situation is different, in different cultures. Oh well, just another routine day at work. It was then that I thought it would be amusing if I were to compile a brief list of some of the many humorous and strange medical encounters that I have experienced in my short career.[[{"type":"media","view_mode":"media_crop","fid":"26884","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_4209332789796","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2566","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: 200px; width: 200px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":" ","typeof":"foaf:Image"}}]]

Sticking with the ultrasound theme, I remember the time when I was in the room helping out one of the techs perform an OB ultrasound (US) on a third trimester fetus. While scanning the patient, and going over the relevant fetal anatomy with the patient, the patient leaned over and asked me, “If I eat a cheeseburger, can you show me my baby eating the cheeseburger, too?” I looked over at the tech standing next to me and we just rolled our eyes.

Or how about the patient who was having twins, and told the tech that she would be naming her twins, Lemonjello and Oranjello, and when asked how she came up with those names, she replied, “Jell-O pudding is my favorite dessert!” Or how about the patient who presented for a pelvic US, and proceeded to moan during the transvaginal portion of the exam, and then asked to have it repeated after the tech had finished.  Are you kidding me?

Then of course, are the many strange but true requests that doctors write for their patients. For instance, US pelvis: “evaluate fibroids” in a patient who has had a hysterectomy. Or, US pelvis: “evaluate ovaries and follicles for fertility work up” in a 12 year old (Seriously?). Or US great toe: “ingrown toenail.”

Then, of course, I will never forget the one time when a young female patient that was sent in for a CT abdomen. The doctor’s note said, “weight gain, and increasing abdominal distention.” The patient was placed on the CT scanner, and after the scout localizer was done, I told the tech to stop the study immediately, and get the patient up off the table. She looked at me once, and then back at the monitor to see that the patient was pregnant, and carrying a near term infant! I had to control myself with all my willpower, when I called the referring physician to tell him that I had figured out why his patient was gaining weight, and her abdomen was getting more and more distended. Come on!

Another classic encounter occurred to me during my first year in practice, when one night when I was on call, I received a call from one of the X-ray techs telling me that the emergency dept was requesting a retrograde urethrogram on a patient who had sustained “penile trauma.” When I arrived at the hospital and entered the fluoro room with the patient waiting there, I asked him what had happened, he told me that he had been doing gymnastics, and that he fell and landed on his penis. That was when his girlfriend, who was sitting next to him, suddenly interrupted and said, “No, that ain’t true. Maybe you were doing gymnastics naked on me, but we was having sex, when your penis just up, and broke in half!”

But even though these stories are amusing and humorous, and add some degree of levity to the daily grind of work, it never diminishes the seriousness of our job as physicians, and our role in helping to take care of our patients to the best of our ability.

Patients should be treated seriously, but that doesn’t mean there aren’t some head-scratching moments in a radiologist’s day.

A Radiologist’s Strange and Humorous Encounters

I have to admit it. Sometimes it blows my mind that some of my colleagues in other fields of medicine still believe that radiologists are not “real” doctors. I truly believe that the prehistoric vision of the radiologist sitting in a dark room reading a few chest X-rays, a couple CTs and a smattering of ultrasounds, and out the door and home by 3:30 pm, still stands.

In our world, we all know that this is the farthest thing from the truth. The majority of us would agree that we are working harder now, reading more cases and being asked to do more with less, than in previous years. Even though we hear that volumes are down, it doesn’t seem that way to me. Our colleagues in the ED, the intensivists in the ICU, the hospitalists on the floors and the primary care docs and specialists in the outpatient world seem to be ordering more and more studies.

Let me preface the following story by saying that this account actually happened, and that there has been no embellishment for the sake of entertainment or to provide humor. I kid you not.

The other day at work, while assigned to the CT rotation, one of the CT techs called to tell me that one of our referring surgeons had sent in a patient of his for a CT of the abdomen and pelvis, with IV contrast. The patient had a complicated history of multiple prior surgeries for bowel obstructions, and reportedly had prior CTs done at outside institutions for such.

The doctor’s request stated, “abdominal pain; evaluate for bowel obstruction.” As per protocol, when the technologist queried the patient as part of our department’s routine screening, the patient told the technologist that after a previous CT scan with contrast, she developed hives, chest pain and tongue swelling that required her to be admitted to the hospital.

When the technologist relayed this story to me, it was a no-brainer. Any patient having a previous reaction to IV contrast predisposes that patient to another reaction. We would do the study without contrast, as having IV contrast is not essential to diagnose a bowel obstruction, and certainly, the risks of a serious contrast reaction carries more weight than anything we would not be able to diagnose on the study.

I instructed the technologist to notify the patient and the surgeon of this, and assumed that the issue had been put to rest. Much to my surprise a few minutes later, the technologist called me back to tell me that the surgeon wished to speak to me. Huh? Mind you, I know this doctor fairly well, and he has a decent reputation. I do not have nor have had any conflict with him in the past. He proceeded to tell me that despite the patient’s history of having a legitimate contrast reaction in the past, he wanted the study to be done with contrast, and when I asked him why, his response was, “there is a better chance of seeing a bowel obstruction with contrast.” Hmmm. Had to think about that one for a minute.

After about three seconds of thought, I asked him, “Just out of curiosity, where did you come up with that idea?” To which he replied, “It’s a known fact, and it’s what I was taught in my surgical training. I will assume the risk and I discussed this risk in detail with my patient.” Wow. Must have been some surgical residency program. Not going to argue with that logic. Then to cover my behind, I figured I needed to talk to the patient and inform her that despite what her surgeon has told her, it goes against what

 am telling her to do as a radiologist, and it also goes against what 

 training has taught me. I told the patient in clear language that what she was about to do was against my advice, and that I would not assume any responsibility for her actions. She understood all of this, and I made sure to document such (in 10 ft letters!) all over her chart. I relinquished control, and was resigned to do the study, as ordered. Planning ahead, I alerted our dept. nurse of the impending CT and its potential consequences.

No sooner than about three minutes after the scan was performed, I was called into the scanner because the patient developed hives all over her neck and torso, and told me that her tongue was feeling puffy. Her face was flushed, and she became tachycardic. Gee, you think it’s a contrast reaction? While these symptoms were running their course and I was resuscitating her with IV fluids, supplemental O

, IV Benadryl and soothing words of comfort, etc. She had the audacity to ask me, “Why was this happening to me?” Hmmm let me think about that for a minute.

Luckily, the patient’s symptoms subsided after about one hour, and she was back to her baseline. When she was feeling better, I again attempted to advise her that what she had just experienced was clearly a reaction to IV contrast and that she should be aware of this for the future if she is to require subsequent CT exams. The consequences could easily have been worse and even result in death.

What was her response? “Thank you for your help. I should have trusted you, but now all of this has made me late for my next doctor appointment.”

Radiologists tend to get a bad rap, but when it comes to imaging studies, we know best.