Paul Dubbins, MBBS

If my wife is right, I am, in fact, a woman. She and other women in my life all maintain that only women can multitask. Yet there is published evidence that I and all of my male associates work in an environment that is interrupt-driven with high multitasking loads.1 Superwoman, eat your heart out.

It is not just my professional life that is interrupt-driven. I am interrupted when I’m watching soccer to go and mow the lawn, interrupted when I am doing online research (what is the best site for French wine?), interrupted when I am deep in thought on how to resolve the economic crisis-and no, I was not asleep!

Now I have ample evidence to explain why the other behavior driving complaints leveled at all males (we never listen!) is designed specifically to reduce error.

“Multitasking is bad for patients and interruptions even worse,” I can tell my wife, noting that observations on clinicians demonstrate that doctors are interrupted between six and seven times an hour, that this causes them to spend less time on any given task, and that they fail in nearly 20% of cases to return to the task when they have been interrupted.2

I use this to explain to my wife why the garden gate still consists only of the surrounding frame. And I can tell the chief that I failed to meet my targets because I was interrupted and that I forgot to return to the reporting work list after that idiot from the emergency department burst in to show me his latest triumph of FAST scanning.

The “no interruptions” sign has gone up on the office door and anyone who enters had better watch out. I can now relax in solitude and silence, dim the lights, adjust the ambient temperature, make sure the viewing station is at the right height, modify the mouse and keyboard to minimize repetitive stress injury, swear at the voice-activated transcription, and I’m ready for a high-volume, low-error workload.3,4 And just to show that I view my consultant responsibilities seriously, the sign also says I am available for consultation between 8:30 and 9:00 a.m. each day (i.e., during the daily ward round).

Some radiologists have adopted this stance. Apparently supported by the literature, they lock themselves away, free from distraction, to carry out their primary role of reporting images. They argue that surgeons would not tolerate interruptions during surgery and that a gastroenterologist would complain vigorously if we were to discuss the finer points of a chest x-ray in the middle of a sigmoidoscopy.

They miss the point. While I agree that to be interrupted compromises patient safety and/or privacy, the value of a radiologist, as of all doctors, is the ability to multitask, to work under pressure. Much of our work is to deal with urgent and emergency conditions, to respond rapidly and accurately to complex and evolving problems. If I am scheduled for image-guided intervention in the afternoon, I wish to discuss the indications and the state of the patient’s health in advance of the procedure. And if this doesn’t happen when I am reporting, then when?

What about the “radiologist of the day” approach? This has many advantages, but if I have reported a study, the clinician may to wish to discuss the report with me. If the study falls within my area of expertise, it would be inappropriate to discuss it with anyone else. And if I am sticking a needle, tube, or stent into anyone, I owe it to the patient to be briefed properly prior to the procedure.

The stance also ignores other evidence for the causes of reporting inaccuracies including workload, lack of clinical details, poor image quality, and, indeed, attention span. Those reviewing x-rays at airport security spend only 20 minutes at a time in front of the screen. Could it not be argued that interruptions, if managed well, might improve our performance?

Until patients form an orderly queue outside my office at the proscribed time, with their ailments properly triaged, then interruptions will be an inevitable part of medical and radiological practice. We must seek to manage such interruptions firmly and effectively, finishing the review and reporting of a study, if the report is almost complete, prior to diverting our attention, or setting aside the study with a brief note of what had and had not been reviewed so that we can return to it later without cutting corners.

If we are not able to demonstrate skills in multitasking, time management, and effective communication, as well as great accuracy in image interpretation, then our roles, as some would suggest, can be divided into individual competencies and performed by an ever growing flock of task-orientated technicians.

And the garden gate? Don’t tell my wife that it is hidden under a pile of car magazines in the garden shed! I like interruptions but my shed is sacrosanct…

Articles

If my wife is right, I am, in fact, a woman. She and other women in my life all maintain that only women can multitask.

Women have no right to monopoly over multitasking

If my wife is right, I am, in fact, a woman. She and other women in my life all maintain that only women can multitask. Yet there is published evidence that I and all of my male associates work in an environment that is interrupt-driven with high multitasking loads.

“Multitasking is bad for patients and interruptions even worse,” I can tell my wife, noting that observations on clinicians demonstrate that doctors are interrupted between six and seven times an hour, that this causes them to spend less time on any given task, and that they fail in nearly 20% of cases to return to the task when they have been interrupted.

The “no interruptions” sign has gone up on the office door and anyone who enters had better watch out. I can now relax in solitude and silence, dim the lights, adjust the ambient temperature, make sure the viewing station is at the right height, modify the mouse and keyboard to minimize repetitive stress injury, swear at the voice-activated transcription, and I’m ready for a high-volume, low-error workload.

 And just to show that I view my consultant responsibilities seriously, the sign also says I am available for consultation between 8:30 and 9:00 a.m. each day (i.e., during the daily ward round).

I didn’t know it until now but if my wife is right, I am, in fact, a woman. She and other women in my life-family, coworkers, friends-all maintain that it is only women who can multitask. Yet there is published evidence that I and all of my male colleagues work in an environment that is interrupt-driven with high multitasking loads. Superwoman, eat your heart out.



 There is no doubt that it is not just my professional life that is interrupt-driven. I am interrupted when I’m watching football to go and mow the lawn, interrupted when I am doing online research (what is the best site for French wine?), interrupted when I am reading about the Murcielago I will never own, interrupted when I am deep in thought on how to resolve the economic crisis-and no I was not asleep! 

 Now I have ample evidence to explain why the other behavior driving complaints leveled at all males (we never listen!) is designed specifically to reduce error. No longer can she exclaim, when I point to the errors occasioned in the airline or nuclear power industries as a consequence of interruptions and distractions, “Haven’t seen you piloting too many planes of late. And although you may generate a lot of hot air, we still seem to have pay utility bills!” 

 “Aha!” I can reply. “Multitasking is bad for patients and interruptions even worse.”

 Observations on clinicians demonstrate that doctors are interrupted between six and seven times an hour, that this causes them to spend less time on any given task, and that they fail in nearly 20% of cases to return to the task when they have been interrupted. 

 Not only can I use this to explain things to my wife-why the garden gate still consists only of the surrounding frame-but also to the chief-I don’t meet my targets because I was interrupted: I forgot to return to the reporting work-list after that idiot from the emergency department burst in to show me his latest triumph of FAST scanning (“Look! An ectopic pregnancy causing ureteric obstruction!!” he shouts before rushing on to the next emergency, my response, “….or a corpus luteum and parapelvic cysts…” lost in the whir of arms and legs-he really should get a cape!). 

 So. No more interruptions for me! The sign has gone up on the office door and woe betide anyone who enters! 

 And this is really nice: relax in the solitude and silence, dim the lights, adjust the ambient temperature, make sure the viewing station is at the right height, modify the mouse and keyboard to minimize repetitive stress injury, swear at the voice-activated transcription, and I’m ready for a high-volume, low-error workload. 



 And just to show that I view my consultant responsibilities seriously, the sign on the door also says that I am available for consultation between 8:30 and 9:00 a.m. each day (it’s important that this is during the daily ward round rather than after it has finished!). 

 There are those within radiology who have adopted this stance. Apparently supported by the literature, they lock themselves away, free from distraction, to carry out their primary role of reporting images. They argue that surgeons would not tolerate interruptions during surgery, that a gastroenterologist would complain vigorously if we were to discuss the finer points of a chest x-ray in the middle of a sigmoidoscopy. 

 I think they miss the point. While I agree that to be interrupted during a radiology procedure compromises the safety of the patient or during an intimate examination compromises their privacy, the value of a radiologist, as of all doctors, is the ability to multitask, to work under pressure. Much of our work within hospitals is to deal with urgent and emergency conditions, to respond rapidly and accurately to complex and evolving problems. If I am scheduled for image-guided intervention in the afternoon, I wish to discuss the indications and the state of the patient’s health in advance of the procedure. And if this doesn’t happen when I am reporting, then when? During a prostate ultrasound? A joint injection? A defecating proctogram? 

 What about the “radiologist of the day” approach? I am sure this has many advantages, but if I have reported a study, then it is usual for the clinician to wish to discuss the report with 

, unless a second opinion is sought. If the study falls within my area of specialist expertise, then it would be inappropriate to discuss it with anyone else. And if I am to be asked to stick a needle, tube, or stent into anyone, then I owe it to the patient to be briefed properly prior to the procedure. If I am to supervise experienced trainees, I can either pace up and down outside the procedure room like an expectant father or I can do something else productive and recognize that I will be interrupted if the trainee encounters something unexpected that is beyond his or her competence or level of training. 

 The stance also ignores other evidence for the causes of reporting inaccuracies including workload, lack of clinical details, poor image quality, and, indeed, attention span. Those reviewing x-rays at airport security spend only 20 minutes at a time in front of the screen. Could it not be argued that interruptions, if managed well, might improve our performance? 

 Until patients form an orderly queue outside my office at the proscribed time, with their ailments properly triaged, then interruptions are an inevitable part of medical and radiological practice. 

 We must seek to manage such interruptions firmly and effectively, finishing the review and reporting of a study, if the report is almost complete, prior to diverting our attention, or setting aside the study with a brief note of what had and had not been reviewed so that we can return to it later without cutting corners. 

 If we are not able to demonstrate skills in multitasking, time management, and effective communication, as well as great accuracy in image interpretation, then our roles, as some would suggest, can be divided into individual competencies and performed by an ever growing flock of task-orientated technicians. 

 ….and the garden gate? Don’t tell my wife that it is hidden under a pile of car magazines in the garden shed! I like interruptions …. just not during the World Cup! 




DR. DUBBINS is a consultant radiologist at Derriford Hospital in Plymouth, U.K. 

Coiera E. Clinical communication – a new informatics paradigm. Proc AMIA Annu Fall Symp 1996:17-21.

Westbrook J, Coiera E, Dunsmuir WT, et al. The impact of interruptions on clinical task completion. Qual Saf Health Care 2010 May 12. [Epub ahead of print].

Berlin L. Defending the ‘missed’ radiographic diagnosis. Am J Roentgenol 2001;176(2):317-322.

Stephens S, Martin I, Dixon AK. Errors in abdominal CT. J Med Imaging 1989;3:281-287.

Radiologist discovers his female side as multitasking demands escalate

Living in England has inevitable consequences, ones shared with most of Northern Europe. The winter is long and dark, and, in South West England, also wet and cold. We are unable to wait until spring to lighten our spirits. We seek more daylight, more sun. So along with the French, the Dutch, the Belgians, the Germans, and the Scandinavians, we make the long pilgrimage south.

Being radiologists, the “SAD syndrome” is particularly severe. We travel to work in the dark, spend all day in the dark, and travel home in the dark. And being radiologists, we are blissfully ignorant of the warnings of our dermatology colleagues about the dangers of solar energy. Yes, of course I use factor 15 to 20 sunblock and I wear a hat. But I also lie in the sun and soak up its warming rays. I need to relax. The journey to the sun was already too stressful; I have already worried myself half to death about issues much closer to my own specialty.

Like many left-of-center conservatives, I was convinced that the media were right: the world had become a dangerous place. Terrorists are around every corner, and slightly left-of-center radiologists are almost certainly their prime target. I was comfortable with the introduction of full-body scans at airports. I am a scientist and have read in detail about the nature of the radiation. Apparently they use one of two different types of scanning systems:

 that produces lowlevel radiofrequency energy with values measured in terahertz (tHz). Unlike x-rays and UV rays, mm-wave photons do not carry enough energy to break chemical bonds or ionize atoms and molecules; they possess even less energy than visible light photons.

 To a radiologist, this is even more straightforward. Understanding the Compton Effect was an early lesson of physics lectures, and the absorbed dose is extremely low.

The U.S. Environmental Protection Agency offers further reassurance: “Most of the scanners deliver less radiation than a passenger is likely to receive from cosmic rays while airborne.” Scanned passengers are likely to absorb only 0.1 to 5 μSv of radiation. So my only worry was whether half an hour in the gym would be enough to avoid an outbreak of giggles among airport security staff as my somewhat less than Adonis-like physique presented itself for review. That is, until our family debate about the Shock Doctrine.

Always more susceptible after a good dinner and a few glasses of wine, the argument that my son presented of the use of global threat and disaster as a means of manipulating society seemed compelling.

How much did I really understand about mmwave technology? After all, it is measured in tHz and that in itself is fairly scary. My cursory review of the literature was shown to be exactly that, and a rather more in-depth assessment revealed some legitimate health concerns.

Mathematical modeling studies show that tHz fields may interact with double-stranded DNA in a way to produce nonlinear reactions or resonances. These have the potential to unzip DNA, creating bubbles in the double strand that could significantly interfere with processes such as gene expression and DNA replication.

I was not reassured by the somewhat bland platitude that currently deployed body scanners operate in an mm-wave region above the submillimeter or tHz region investigated in the study I was looking at. So, coming from a country where individual choice is paraded as a human right, I was mulling over whether to request mm-wave or x-ray backscatter.

There is little doubt that the doses from the backscatter x-ray systems being proposed for airport security purposes are said to be very low, but by now I was calculating the cumulative dose for a frequent flyer. I was weighing up the pros and cons of refusing the body scan altogether and submitting myself to an intimate body search, but the very thought of the rubber glove induced a serious attack of irritable bowel syndrome. I resolved to pack a lead coat in my carryon luggage-although this left only enough room for a tiny pair of Speedos dating back to the 1970s.

In the event, it was only my wife who was searched and neither of us was submitted to a body scan. She has this innocent smile that is always interpreted as an attempt to hide evil intent. Nobody was the slightest bit interested in the lead coat, although the Speedos produced barely stifled giggles not only at airport security but also throughout the holiday...

Living in England has inevitable consequences, ones shared with most of Northern Europe. The winter is long and dark, and, in South West England, also wet and cold.

Airport scanners raise the ceiling on a fear of flying

Recently, I spent a week playing with dolls and learning how to wash my hands. Am I regressing? Probably, but that is not the reason for the week's activities. No, I was attending a statutory training course where I learned (yet again) how to deal with cardiac arrest, the importance of hand washing, and the location of fire extinguishers.

I have been learning how to resuscitate patients for the last 40 or so years, so you would think that I might have cracked it by now. Evidence from Europe and North America suggests, however, that radiologists' knowledge in this area is somewhat lacking. In a U.K. study published in the October issue of the 

 (Tapping CR, Culverwell AD. Are radiologists able to manage serious anaphylactic reactions and cardiopulmonary arrest? 2009;82[982]:793- 799), only 13% of those responding to a questionnaire demonstrated full knowledge of guidelines produced by the national Resuscitation Council. When radiologists in Canada were questioned about the use of epinephrine (adrenaline) in an emergency situation, only 41% provided an acceptable route of administration, concentration, and dose. None produced an ideal answer. In fact, 17% prescribed an overdose and only 11% knew what was available on the crash cart (Lightfoot CB, et al. Survey of radiologists' knowledge regarding the management of severe contrast material-induced allergic reactions. Radiology 2009;251[3]:691-696).

Can we even guarantee to provide effective external cardiac massage? How many chest compressions should you do before you attempt rescue breathing (mouth-to-mouth resuscitation), and where in the world is the CPR mask kept?

These are chilling statistics. Imagine lying on the couch with a needle in your arm awaiting an injection of CT contrast. Would you really want to ask the doctor: “When was the last time you had to deal with a case of angioneurotic edema?” Or: “When was the last time you attended a resuscitation course?” Approximately 40% of radiologists in the U.K. would probably answer: “Over four years ago.” This despite the fact that annual training is mandatory here.

So why are we no good at playing with dolls? Resuscitation mannequins have become ever more sophisticated, allowing clinical scenarios of variable complexity to be replicated and offering both positive and negative feedback. Why are we reluctant to attend courses that are designed to revise and rehearse basic skills? If we attend those courses, why are we so poor at retaining knowledge?

We are often reminded that airline pilots must undergo extensive training in how to deal with a variety of adverse weather conditions, equipment failure possibilities, and other emergencies. They appear able to maintain their skills. I suppose it must feel more real to sit in a simulator that looks like a flight deck, where instruments are flashing warnings, than it is to be in a classroom with an inanimate mannequin. In an aircraft simulator, the altimeter spins terrifyingly if you are in a stall and the ground appears to rush towards you. Does our resuscitation doll go blue? Does she gasp, and do her relatives start screaming? No. Instead of actually demonstrating the features of respiratory or cardiac failure, we have a series of electronic warnings. This is not a real life (or death) situation.

It is difficult to take medical emergency training seriously when you don't feel under pressure. So how do we create an environment where radiologists and other healthcare professionals look forward to and even prepare for resuscitation training? In the U.K., this will become compulsory as part of a new process of professional revalidation. But will we actually have to pass or will it be enough to simply turn up?

An airline pilot would be grounded if he or she failed to pass the regular test of “skills under duress.” Should radiologists also be barred from practicing if they are unsuccessful during an assessment of their resuscitation skills? After all, 2% to 3% of hospital crash calls are made from the radiology department. We can all expect to deal with at least one emergency during our professional life.

Radiologists should be worried about more than the threat of losing their job. Fear of unemployment will undoubtedly concentrate the mind and possibly affect performance. But does this accurately reflect the stress you must confront when faced with a patient who is pale and sweating, hypotensive, and unresponsive, or who has progressive stridor as their laryngeal edema becomes more and more severe? Not really.

The compulsory resuscitation training in the U.K. is generic. I learn alongside hospital porters and secretaries, as well as nurses and other doctors of all grades. Some of the skills are indeed generic and all health workers should certainly learn external cardiac massage. The emergencies that occur in the radiology department are, however, reasonably predictable: cardiac arrest, adverse reaction to contrast, and postprocedural or postoperative bleeding leading to shock. On two occasions, because of the mixed group, I have had to resuscitate a woman with postpartum hemorrhage during training. I am now one of a few radiologists who perform antenatal ultrasound, but I have never had to deal with an acute postpartum hemorrhage in practice.

Resuscitation training should not only be compulsory, it should also be relevant to specialist groups. Radiologists should be trained and tested in emergencies that are likely to occur in the radiology department. In addition, a simulator model should be developed that better recreates the emergency environment. The “patient” needs to look like a real patient, the emergency call needs to be unexpected, an aura of anxiety needs to be fostered that can be calmed by effective actions of the radiology department team and made worse if the actions are not coordinated or effective. If we can respond effectively in such an environment, passing the test we will make us much more likely to cope effectively with genuine emergencies.

We have a responsibility to contribute to the development of training methods, methods of evaluation, and simulated environments that will ensure that our response to emergencies is second nature and our patients are better protected. I am not convinced that even those of us who undergo annual compulsory training are properly prepared at the moment.

On a lighter note, there is an alternative to increasing the sophistication of the simulation. Why not make the mannequins look like Keira Knightly or George Clooney? Then we might all become more enthusiastic about practicing chest compression and rescue breathing…

Recently, I spent a week playing with dolls and learning how to wash my hands. Am I regressing?

Breathing new life into resuscitation training

I was never very good at the classics at school. I guess I never really fancied the Latin teacher in the same way I did the French 

. The languages appeared so dry and so dead at the time, and although we learned “amo, amas, amat…,” there was not the same potential to apply this newfound knowledge. Foreign exchange trips did not take in ancient Rome or Athens, so there was no opportunity to impress a local “puella” with your extensive understanding of Caesar’s Gallic Wars.

Perhaps medical school witnessed a slight enhancement of my enthusiasm for Latin and Greek derivation; anatomy viva-voce examinations made that almost a necessity. But it is only lately that I have become concerned, some would say obsessed, with the proper use of language. The use of Latin and Greek, and occasionally German, words for the description of anatomy and pathology allows the language to be almost universal among medics and therefore affords an understanding between practitioners from all over the world. Why, then, have we become so lazy?

I have become used to the way in which the English language has been modified to accommodate American tastes: foetus becomes fetus, for example, although I remain unable to accept etiology rather than the correct form of aetiology.

I can understand the difficulty that some may have with the use of English, especially when it is not the mother tongue. I can also understand their confusion over certain words incorporated into medical use because of an association with an individual. For example, it is difficult to determine whether and when to capitalize the word Doppler. Should it be capitalized when it’s used in recognition of the scientist who first appreciated a frequency change with motion? What about when it’s used to describe a technique such as “color Doppler”? Capitalization questions aside, however, use of the word as a verb offends my sensibilities.

Perhaps I am being unreasonable if I lay the blame for much of the etymological and grammatical abuse at the door of Americans, but it is they who suggested the description “endovaginal,” notwithstanding that they cannot pronounce the word. Mixing Greek and Latin derivations within the same word cannot be acceptable to any lover of language. Transvaginal is preferable, but I still believe that pervaginal or intravaginal represent more accurate terms.

Sadly, however, it is my own residents and younger colleagues who have awakened the lexicographic Kraken in me. What is so difficult about the filamentous membrane that divides two locules of a cyst? This is a septum. Only if there are two membranes do they become septa, and in no situation are there such things as septae. The same applies to the outpouchings of the colonic wall. These are known as diverticula if there are several but as a diverticulum when there is only one. Diverticulae or diverticuli do not exist.

Some words are, of course, difficult. Adnexus relates to an accessory or adjoining part, such as the ovary or fallopian tube. Even the lexicographers have become confused when determining how to employ the plural, namely “adnexus,” and have employed the neuter plural adjectival form, “adnexa.” Somehow, however, the “e” enthusiasts have had a field day. Not content with creating a plural neologism in the form of adnexae, I have seen an increasing use of a completely new word: the adenexa.

Why do the generative organs create so much confusion? I completely fail to understand the confusion with respect to the male gonad, but it remains the case that a single testis is frequently labeled as the left or right testes!

Perhaps it doesn’t matter. Perhaps I should have another glass of wine and accept that language changes- adapts for current use-and bow to classical derivations being consigned to history.

“Do the terms proximal and distal cause confusion amongst radiologists and other clinicians?,” an article from the April issue of 

 (2009;64[4]:397-402) demonstrates how the unqualified use of terms can cause confusion. The words proximal and distal demand a reference point if they are not to be misinterpreted. When using these terms to describe certain anatomical structures, the author found significant conformity in the descriptions when applied to the common bile duct but discordance when they were used to describe the ends of the superior vena cava or jugular vein. Such discordance may lead to significant medical error. One is reminded here of the female medical student asked to describe a lesion on the tip of a penis. Challenged when she described the lesion as being on the proximal end of the penis, she retorted that it may be distal to you, sir, but it is proximal to me! The terms are clearly not absolute.

Most depressing of all, however, are suggestions that certain anatomical structures be completely renamed to avoid confusion. Apparently, the superficial femoral vein is ill understood by many young doctors who do not recognize that it is part of the deep venous system of the leg. Thus, if I report that there is an occlusive thrombus extending from the popliteal vein into the superficial femoral vein but not into the common femoral vein, there is either confusion as to how the thrombus can flit so easily between superficial and deep venous systems or total lack of concern on the part of the clinician, having been reassured that there is no deep vein thrombosis.

So should these vessels really be renamed the proximal and distal femoral veins? Does anyone else begin to feel uneasy? Proximal or distal to what, we should be asking.

Whatever happened to detailed anatomical knowledge as part of the medical curriculum?

I think I will have that other glass of wine… But do I pour from the proximal or distal end of the bottle?

I was never very good at the classics at school.

They're only words, butthey really do matter…

Radiologists in Manchester, U.K., and Ghent, Belgium, have carried out highresolution CT on the 50-million-year-old fossilized remains of a spider embedded in amber, according to a report from October 2007 on physorg.com. This revelation caused me to ponder spiders. I have plenty at home in the shed, in the loft, certainly in the bath. However, I cannot ever remember seeing a spider in an x-ray department. Flies, wasps, bees-yes, all of these, but never a spider.

Many x-ray departments I have worked in have been located in the hospital basement, surely an ideal home for spiders. But there were none to be seen. The department I work in now is on the sixth floor, so perhaps the dearth of spiders is due to vertigo? Somehow I doubt that. It would be reassuring to think that the absence of arachnids is due to the spectacular cleanliness of hospitals. Looking around my office suggests otherwise, yet the only webs and web crawlers in here are on my PC.

Now I know why. Evidence indicates that the release of radiation from the Chernobyl nuclear reactor has had an enormous impact on the distribution of spiders in the surrounding forests. The number of spiders and webs is less than a quarter than would be expected. Maybe this explains the scarcity of eightlegged creatures in x-ray departments.

The response from arachnophobes may well be: “Good riddance.”

Radiation safety is a big deal not just for spiders. We are entering an era of heightened awareness of the risks of medical irradiation. The Image Gently campaign to promote exposure reduction for pediatric patients (imagegently.org) and the appearance of radiation safety advice on YouTube are two examples of this.

The overall radiation dose to the U.S. population from medical imaging has increased more than sevenfold since the 1980s and now accounts for nearly 50% of all environmental radiation. Radiation exposure from medical procedures is now equivalent to the background radiation dose and it is growing year on year.

For many observers, the widespread use of multislice CT is responsible for this increase. CT may be responsible for 1% of total deaths from cancer, rising to 2% in some pediatric patient groups. No need to tell that to the spiders of Chernobyl, assuming you can find one to tell.

New dose reduction strategies are being developed for pediatric examinations and for high-dose procedures, such as cardiac CT. In addition, radiologists and other clinicians should be adopting a policy of justification when considering the use of ionizing radiation. Knowledge of a patient's imaging history to avoid unnecessary repeat examinations, selection of alternative imaging modalities, and a little bit of clinical common sense are critical to safer imaging.

There are a number of clinical situations where CT is unequivocally the primary tool of choice, and perhaps the only appropriate modality. In other situations, ultrasound may be equally relevant or perhaps even more appropriate. Radiology trainees must become adept at performing ultrasound for acute conditions, particularly in children and young women, for whom the lifetime risk from radiation is higher and in whom ultrasound has the greatest diagnostic potential. If radiologists are to provide a robust urgent and emergency service for these two groups, then they need to be comfortable performing pediatric examinations and confident of their transvaginal ultrasound skills. A straw poll that I conducted at a national meeting for emergency radiologists suggests that this is not the case at present.

Radiologists' increased confidence with CT has perhaps been gained at the expense of their ultrasound skills. The ultrasound unit, and in particular the transvaginal probe, is the only place you are likely to find a spider's web at the weekend. The spider knows it will not be disturbed here!

The spider could actually be a good role model for radiologists. The 14th century Scottish king, Robert Bruce, was apparently inspired to continue fighting the English by the repeated and untiring efforts of a spider that was spinning a web in the face of huge logistical difficulties. If we are not as tireless and diligent as that spider in ensuring the appropriate use of ionizing radiation in medical imaging, then arachnids may not be the only ones to suffer.

Radiologists in Manchester, U.K., and Ghent, Belgium, have carried out highresolution CT on the 50-million-year-old fossilized remains of a spider embedded in amber, according to a report from October 2007 on physorg.com

Ionizing radiation worriesmeet arachnophobia

Medical school, postgraduate training, continuing medical education . . . in common with most other doctors, I have been learning throughout my career. I sometimes, perhaps rather pompously, consider myself to be an expert, or at least a specialist. Yet now it appears that I need guidance on almost every aspect of my professional life as a radiologist.

We are inundated with advice on how to perform our role. Guidance and protocols emanate from a variety of sources and cover an ever-increasing variety of topics. What to image and what not to image; which imaging modality for what indication; what sequences to employ for which anatomical sites and clinical conditions. We even receive advice on what data to record.

I am beginning to sound like a reactionary old fart. Surely, I cannot be against the development of best practices and the dissemination of information that will ensure such practices benefit patients worldwide?

Well, no, not exactly. But consider the environment in which these guidelines are developed. A group of eminent specialists is drawn together to consider a selected topic. It is likely to be six weeks before the group even has its initial meeting.

The aims of guideline development are discussed and agreed, and a literature search strategy is approved. Delay before agreement? Possibly another six weeks.

The literature is collected, collated, and circulated to the relevant specialists for their opinion. A Delphi process may even be employed to ensure scientific rigor. Delay: 12 weeks?

The detailed guidance is drafted and circulated to all group members. Comments are sent, received, and incorporated into the final draft, which is again circulated. Careful indexing, referencing, and copyediting are undertaken. Twelve weeks to complete these steps?

Electronic publishing means that the document should now be available. In practice, most doctors will become aware of the publication only when the hard copy arrives, perhaps six weeks later.

At best, the process has taken nearly a year, and it can often take longer. The result? An abstracted literature review, delivered in glossy format and accompanied by expert opinion, appears at least a year after the most recent article referenced in it was published.

The effect that such documents have on practitioners is complex. Do I stop thinking about the care of my patients if I have a guideline to follow? Do I stop reading the literature if a comprehensive overview will be published in a few months' time? Do I need to remember what I learned at medical school in the 1960s? Do I need to be a medical practitioner if all the difficult decisions are made by the clever people who produce these guidance documents?

Don't get me wrong, I do believe that guidelines can help improve healthcare services. But they can also promote laziness, suppress intellectual challenge, and lead us to ignore the individuality of different patients and their expectations and needs.

We have, for example, introduced a protocol for the investigation of suspected deep vein thrombosis. This condition is no longer managed by a doctor because the pathway is clearly defined. Try explaining to the nurse managing the process that the patient does not need a follow-up venous ultrasound to detect the 
pro-pagating clot because I have already diagnosed a ruptured Baker's cyst. This tries my limited patience sorely.

All guidelines are eventually ignored. The updating process is resource-intensive, and many guidelines, sadly, rapidly become outdated. Is this the best we can hope for, that guidelines have a limited shelf life and that you will still have to read original articles?

There are exceptions, of course. Do you remember receiving guidance regarding the investigation of low back pain? When I began in radiology, we received clear advice that a lumbar spine x-ray was of no value for acute or chronic low back pain in the absence of suspicious clinical findings. Yet how many lumbar spine x-rays have I seen over the last 30 years?

Now we have another report that says imaging in cases of acute and chronic low back pain is of no value in the absence of red flags. The only difference is the modality, this time MRI.

Someone needs to tell primary care physicians that they are supposed to read guidelines, not use them to wallpaper the toilet. Or maybe they are thinking for themselves and recognize that a little bit of imaging can do you good.

Medical school, postgraduate training, continuing medical education . . . in common with most other doctors, I have been learning throughout my career. I sometimes, perhaps rather pompously, consider myself to be an expert, or at least a specialist.

Guidelines and protocols: What should I really be doing?

Health tourism has never appealed to me much. I am privileged to live in a country where healthcare is considered a basic human right and where, while quality and access may not be perfect, the standard of care nonetheless remains high. If my hip needs resurfacing, I am not sure I would wish to travel even 200 miles up the motorway to Birmingham.

When I have my heart attack, I want to be in a hospital where I understand what the doctors and nurses are saying, my family is close by, and the quality of food is so poor that my greatest risk is malnutrition. But I delude myself. Over 30% of doctors practicing in the U.K. were born elsewhere. Happily, this does not concern the polyglot English. I will use linguistic skills to make myself understood, just as my compatriots do: I will speak more loudly than usual and with an even greater level of exasperation. That should do it!

I recognize the advantages of a pleasant environment for recuperation. My preference is a month convalescing in Mauritius after every attack of “man flu.” If I am to travel to deliver my professional skills, then there have to be certain attractions. I have always considered that practicing mammography in St. Tropez would be particularly intellectually challenging.

Doctors and patients have always traveled, either to gain more experience or a different outlook on healthcare, or to seek high-quality healthcare perhaps unavailable at home. The nature and volume of traffic has changed over the past few years, though. Much of the travel by professionals was previously between commonwealth countries, from the U.K. to the U.S., from France to Canada. Travel by patients was largely restricted to the wealthy few who could afford the cost of the journey and the high costs of private healthcare.

Travel within Europe did occur but to a lesser extent. The opening of European boundaries has changed the trickle of health tourists into something more approaching a flood. Now patients are seeking faster, better, safer, and/or cheaper treatment, wherever it may be found.

The U.K. has welcomed (if that is the right word) many new doctors from elsewhere in the European Union. Since 2003, more than 20% of new registrants for medical practice in the U.K. have come from continental Europe. Around 15% of these have come from Germany, making it inevitable that Germany will seek to fill its medical practitioner coffers from elsewhere. I imagine that the exodus of doctors from some areas in Europe will put a significant strain on the healthcare systems of those countries. In 2005, for example, nearly 50% of doctors in Ireland who had just finished their training left the country. Malta lost nearly 25% in a similar exodus.

In clinical radiology, neither the patient nor the radiologist actually has to travel. Image transfer and teleradiology have made national barriers almost irrelevant. The free movement of doctors throughout the EU, and the even freer movement of patient information, has much to commend it. There are also some very significant problems. The exchange of ideas, the ability to learn new skills, and greater workforce flexibility are all cited as advantageous, but, as already mentioned, this comes at the risk of draining specialist skills from certain countries and destabilizing healthcare systems. Some countries have expressed concern that while migrant doctors and those participating in teleradiology programs may have great 
linguistic skills, they do not understand the finer nuances of the language they are reporting into or the complexities of the various healthcare systems.

The added complication of recertification has now entered into this mix. We have long assumed that fitness to practice medicine is a lifelong capability bestowed on receipt of a medical degree and that specialist practice similarly requires only a one-off qualification. From then on, you need only turn up for work every day, switch on the PACS (having remembered the password), and growl into a tape machine or voice-activated transcription device. This is enough to demonstrate that your specialist radiological skills remain intact. If you audit the things you know you are good at, the results are bound to show you in a good light. You return home happy in the knowledge that you can still cut it with the best.

Not any more. A number of high-profile cases in which the quality of patient care has been called into question-or worse, where a general practitioner was convicted of serial killing-have provided the impetus for a process of revalidation or recertification in the U.K. Radiologists will now be required to demonstrate diagnostic and therapeutic skills on a regular basis, based on peer review of practice and evaluation of audit outcomes. Potential personal problems, such as drug abuse, mental health issues, and alcohol usage, will be assessed as well.

The process of formal recertification might be peculiar to the U.K. within Europe, but it is already well established in the U.S. What will this mean for the free movement of radiologists or the wider availability of radiologists' expertise through teleradiology? Clearly, all radiologists practicing within the U.K. will be subject to the same constraints. There seems little doubt, however, that the potential for outsourcing reporting work to radiologists in other European countries will be compromised.

Directives from the European Commission that mandate the sharing of information about individuals' certification should ensure that information on fitness to practice is available to all EU member states. However, such initiatives have met with little support. Few countries have signed up for full collaboration and some countries have resolved not to participate at all.

We are a disparate group of nations with different cultures and a rich history that is at times inclusive and at other times particular to the nation state. We have a justifiable pride in our own institutions and educational systems. But we are, in many ways, a uniform group of specialists. We are all committed to providing the highest quality diagnostic skills and image-guided therapy for our patients.

Could we not agree that the standard by which we should be judged should be measured by the highest common denominator, drawing on the best aspects of education, training, and supervision from all of our nation states? If we fail to grasp this particular nettle, then all of the strides we have made toward greater pan-European understanding and professional cooperation could be compromised. If the U.K. border is closed to those who cannot demonstrate satisfactory recertification, will all borders then swiftly follow suit?

We could produce a suite of tools that would allow us to evaluate our practice continuously against a series of defined criteria. These criteria could be nation-specific if required. Those wishing to contribute to patient management outside their own national boundaries could take a pan-European “radiology baccalaureate,” to be renewed every five years. Such a qualification would reaffirm our skills, reassure patients across our union, cement our mutual collaboration, and potentially raise standards of education, training, and care for all.

In the more immediate future, I am happy to help anyone struggling with language difficulties by providing lessons in voice projection, irritated looks, and intolerant sighs!

Health tourism has never appealed to me much. I am privileged to live in a country where healthcare is considered a basic human right and where, while quality and access may not be perfect

Medical recertification: putting the walls back up?

The holiday season is over, and it is the time to make New Year's resolutions. What to resolve? My perception that the finished article could hardly be improved upon is frequently challenged by my family. "You could lose weight, you should drink less, you could get home earlier, you could be less grumpy," they tell me.

With so many problems, it was difficult deciding which to address first. I needed help. Perhaps my first resolution should be to consult the computer more often. Google indicated that I needed a decision support system. I really had no idea of the extent to which I could delegate decisions to an inanimate object, thereby blaming not someone else but something else for all my errors and deficiencies.

These computerized information systems store data that can help individuals or organizations make evidence-based decisions. They have increasing applications throughout industry and commerce, as well as healthcare. Apparently, these approaches can be passive (predominantly an information resource), active (the system will provide solutions based on the data), or collaborative (the individual accessing the system can modify the suggestions). Computer-aided diagnosis and clinical support systems fall, at present, into the last category.

, represent an aide memoire for the clinician seeking to determine the best clinical pathway for a patient presenting with a set of symptoms. Others, such as CAD within radiology, allow differentiation of images into specific diagnostic groups that can subsequently be reviewed by the radiologist. This may have specific advantages (e.g., when using imaging for screening).

Like me, perhaps you thought that artificial intelligence was a recent concept in clinical radiology. Not so. I am not sure that Thomas Bayes foresaw the imaging applications of his theories as early as 1763, but CAD of bone tumors was first suggested in 1963, and general radiological applications were proposed in 1966. I must have been watching the soccer World Cup Final because the latter completely passed me by.

CAD has the potential to address a number of issues, the first of which could be our ever-burgeoning workload. Imagine it: an entire department of virtual colleagues. I could pick and choose the examinations I reported. I could schedule my duties so that I never worked during public holidays but was always on duty during the January retail sales. I wonder if we could get these colleagues to do the defecating proctograms?

I would have to learn a completely new language, but then I have always been adept at spouting meaningless drivel (ref. A Dose of Dubbins). I am sure I could intersperse a few sage comments, such as "using knowledge to create knowledge is the major concept of the emerging knowledge society." I could refer to my own webliography, supporting my own opinion, and wax lyrical about compunetics, perhaps even creating a wikidubbins without really having any idea what I was talking about.

Decision support could go much further. When asked, "Do you prefer the little black dress or the trouser suit?" or "Does my bum look big in this?", I could check with an active decision support system, thereby ensuring an evidence-based answer and avoiding marital strife.

In medicine, CAD can be applied not only to image interpretation but also to clinical diagnosis, to determine management pathways and support remote prescribing. It can streamline the patient's journey, ensuring greater consistency of care and saving costs, particularly where the cost of different management options with similar clinical outcome is included in the data. In remote communities, clinical care could be supported by access to an expert knowledge base structured to guide management decisions.

Within radiology, the potential to address workload and workforce issues is immeasurable. "There is an urgent need to provide assistance in handling the several million radiographs read by radiologists each year. The need for computer-aided diagnosis is becoming increasingly urgent." Amen to that. Except that this quote was made nearly 40 years ago, and I have still not seen a reduction in my PACS work list.

The biggest disappointment to come out of my newfound enthusiasm for all things IT is that my vision of a stress-free workplace with compliant virtual colleagues has been challenged. Apparently we cannot get on. Three different types of workplace tension are likely when using decision support or electronic knowledge resource: between doctor and inanimate object, between doctor and other healthcare workers, and between doctor and healthcare organization.

Of course, it wouldn't happen in my department, so long as everyone and everything realized that I am always right. And I could always kick the computer like I always have done. They don't kick back . . . yet.

The holiday season is over, and it is the timeto make New Year's resolutions. What toresolve? My perception that the finishedarticle could hardly be improved upon isfrequently challenged by my family.

Paul Dubbins, MBBS

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