The legendary radiologist Ben Felson was known for saying that he learned more radiology from following up on his interesting cases than by any other means. The equally legendary physician Sir William Osler paraphrased this by his statement that to learn medicine without textbooks would be to sail an uncharted sea, but to learn medicine without attending on patients would be not to go to sea at all.
I recall the days of my body Imaging fellowship at the New York Hospital, which was now 21 years ago. To this day, I recall in vivid
detail some of the cases where I missed a finding that was subsequently picked up by the staff radiologists, in some cases right down to the name of the patient, and in particular can still feel my chagrin at being informed of my miss. Of course, the result of this was that I did my best to never miss it again.
With reference to the subject of follow up, in the current era of the overworked radiologist and clinician, it is harder than ever to get follow up. In a teleradiology practice it is particularly hard, especially given that the patient has often been referred to a tertiary care center and is therefore effectively lost to follow up.
In our early days, my colleague Dr Anjali Agrawal and I used to personally call the hospital and check with the staff on the floor what the surgical findings on our patient were. This as you may imagine was tedious time consuming and not always productive, as the floor staff were often busy and not alwyas cooperative.
In the recent past, my colleague, Dr Matt Fox has undertaken a very interesting CQI on obtaining follow up of our interesting cases, which involves identifying a clinical partner at each of our client sites and working with them directly. He has had an approximately 50% success rate overall, and all credit to him for his diligence.
Going forward, with interoperability and the integration of RIS and HIS using standards such as HL7, it seems that we should be able to obtain such data more seamlessly. Till then however, the process remains dependent on the tireless efforts of enthused young radiologists such as Dr Fox and Dr Agrawal.
Teachings and Learnings
Technologies such as spiral CT and color Doppler had recently been introduced and suddenly the vascular anatomy of the mesentery sprang into clear focus, as did the evaluation of such conditions as ovarian and testicular torsion and ectopic pregnancy.
Having trained at a top center in India, and with a lot of ultrasound experience under my belt, I was a popular fellow among the ultrasound techs, who would like to come to me to help them solve problem cases. However, my CT interpretation experience was still somewhat limited as my training had focussed more on the solid organs than the GI tract. As the year progressed, I learnt to detect subtle fat stranding and trace the often elusive appendix. I recall a compliment I received from a surgeon, when I diagnosed a case of perforated cecal diverticulitis, and remained adamant in the face of the surgeon’s conviction that it was a perforated appendix. On returning from the OR the surgeon clapped me on the back and said ” you bas***ds do know what you’re doing!”, a reluctant compliment that was music to my ears.
I remember with fondness my mentor and the chair of the department, Prof Elias Kazam, a pioneer in the field of abdominal CT, whose famous aphorism ‘ we are not in the business of ruling out, we are in the business of ruling in’ so true in the era of legal medicine, still rings in my ears. Other such statements that have stuck in my head, and that still ring true, are Bruce McClennan’s simple yet profound “common things are common” something I repeat almost daily t
junior colleagues and Lee Katz’s ” God does not know from straight lines” which in ecclesiastical terms says that a very straight line on a skeletal radiograph is typically a postsurgical change.
So in my opinion, the two greatest learning influences in radiology are getting follow up on one’s cases, and the simple and practical statements passed on verbally by experienced radiology educators and mentors, that exceed in their impact all the millions of words of text that our eyes peruse in the course of our medical education.