Rodney Dangerfield as a radiologist

Dr. Mirvis is the Editor-in-Chief of this journal and a Professor of Radiology, Diagnostic Imaging Department, University of Maryland School of Medicine, Baltimore, MD.

One of the interactions that most bothers me in dealing with my medical colleagues, including many in early training, is the tendency not to take advice from radiologists about the types of studies they should request or the protocols that should be used. When there is disagreement about the indication for a “requested study” or how it should be performed, all too frequently the debate escalates through the medical command structure and opposing positions solidify. The issue becomes a battle beyond the simple medical question at hand. Of course,this is hardly always the scenario. Sometimes the radiologist needs more clinical information to make his/her best recommendation or the requesting physician needs a clearer understanding of the thinking behind the radiologist’s opinion. Unfortunately, many times the consulting physician assumes he/she is “ordering” a study and the radiologist is there to interpret it – not discuss it or how it should be done.Often a radiologist’s advice is perceived as obstructionist. In our institution, many referring physicians insist on a call from the radiologist if they are considering modifying what was ordered instead of doing their job.

Can you imagine an internist advising a consulting orthopedic surgeon on what operation they should perform or a consulting oncologist on what drug regimen is best? Of course not, since these physicians are the acknowledged experts responsible for making these decisions. While many procedures and studies radiologists perform and interpret are straight forward,requiring no additional discussion, that is clearly not always the case. The same, however, doesn’t always hold true with regard to radiologists. Radiologists are often perceived as technicians, not physicians, so our advice is not, in a most general sense, considered so valuable. Obviously, the respect for a given radiologist’s opinion is usually dictated by his/her experience and having established trust. Even given their extensive training, immense body of knowledge about diagnostic imaging and high-value content of information they provide, radiologists’ opinions concerning imaging studies are still not given the respect they should receive. Yes, I realize I must sound like Rodney Dangerfield, the comedian whose signature line was “I get no respect” as he loosened his tie and twisted his neck.

It puzzles me that when I discuss this issue with radiologists from other countries they indicate that they typically do not deal with this situation. If, in their opinion, a requested study is not needed or should be modified to best answer the medical question, that is pretty much the end of the discussion. They cannot understand how it could be otherwise.

The high frequency with which minimal or nonclinical information is provided to the radiologist is another reflection of this lack of respect. More clinical information helps with interpretation for most radiologists, I believe. Failure to provide such information is NOT in the patient’s best interest. Perhaps many nonradiologist physicians just do not want to take the minimal time needed to provide such information,or simply feel if they have this information they can interpret the study, as long as the radiologist is ultimately the “expert” if errors are made. It seems utterly ridiculous that physicians would not want to obtain the highest possible diagnostic value out of what is often an expensive study,usually with extremely high informational value, if it is appropriate for the clinical information sought and correctly performed. Today, given the focus on responsible use of radiation exposure and need for cost containment, one would expect a much greater effort would be made to supply the radiologist with relevant clinical information and rely on his/her opinion for designing imaging work-ups.

Among the reasons that many U.S. physicians may often act in this fashion is the perception that radiologists do not take care of patients,do not understand clinical issues, and perhaps are too “coddled already.” If so, these views are wrong. Still, we radiologists have done a great job isolating ourselves from the action and direct responsibility for the patient’s care. Electronic interpretation has made this far worse as we can be practically anywhere to interpret studies.

To perhaps change the perspective of our “referring physicians” seeing us as consultants, radiologists need to be, at least occasionally, in the thick of clinical care; in the conferences, giving lectures or case presentations, and on ward rounds. We have gone from our view boxes to our PACS workstations, but still confine ourselves to dark rooms, only rarely entered by our referring physicians to discuss a case. It is very important that other medical specialties learn from us, appreciate what valuable information we offer, how much we know about many specialties, understand both how and how hard we work, and that we can, from time-to-time, actually be a physical presence in their patient-centered world. Of course, we are very busy interpreting studies, but we must get out into the light occasionally and play in the same sandbox with “clinical” physicians.

One of my senior mentor faculty members used to get angry when radiology residents referred to nonradiologist physicians as the “clinicians.” He saw our role as equal in patient care to that of the primary physician who is interfacing with the patient and coordinating his/hercare. I never disagreed with him (it was dangerous for one thing), but I always chafed at his opinion. Although many radiologists perform procedures that bring them in contact with patients, this is typically a one-time involvement, and they do not play an extensive role in their overall care.

I always found it a bit humorous that at my medical school, radiology residents were required to carry stethoscopes (at least in their pockets rather than around their necks). It seemed ridiculous to carry something you would never use, assuming you recalled which end went where. Now I realize there was an important message being transmitted to their clinical colleagues; that is, we are in the same game as the rest of you; we take care of patients too.

I am not sure if any of my department co-faculty and residents carry stethoscopes, except possibly the interventionalists. I actually carry a reflex hammer, but more for self-protection than for its diagnostic uses. In my section, we pride ourselves on our casual attire, as if to say, “we are just chillin’ out,” while we do our work and are just easy-going radiologists. “No stress happenin’ here man.” In reality, that is far from the case. We work very hard at odd hours and cope with a lot of stress and challenges. When residents or fellows from other services do elective rotations in our section they are quite surprised to see the intensity of the work and the variety of pathology we must be knowledgeable about. I think we should dress the part of physicians no matter what our speciality. Next week, everybody in my section gets new white coats. Many of us will not fit into our old ones, if we can even find them. I’m sure this idea will be warmly embraced by my section mates, but we have to start sending the right message.