Radiology Rounds

If you have an x-ray done in the hospital these days it will be quickly read by a radiologist with the report available almost immediately. Thanks to the magic of the electronic medical record, your doctor can access the report anywhere the internet is available—the hospital, the office, the golf course.

Even in the middle of the night you can have an almost instantaneous interpretation of your radiology study despite the fact that your hospital’s radiologists are slumbering in their beds or hanging out at the local radiologist watering hole. These days, many radiology groups contract with services that provide nighttime interpretation by doctors in India, Australia, and other places where the sun shines during our nighttime hours. Since modern x-ray images are no longer printed on plastic sheets and hand-carried to the interpreting doctor, they have become nothing more than a collection of pixels and electrons and can be beamed to Bangkok as easily as they can be sent down the hall to the doctor’s office.

You would think that I would applaud the innovation of digital radiology. After all, I frequently bring up the merits of new technology in the medical world (while only occasionally disparaging it). I am a firm believer in the concept of the electronic medical record and love the idea of being to check on patients without physically holding their paper chart in my hands.

In some way, however, I think we’ve taken a step in the wrong direction with our move to digital radiology. To give you an idea of what I mean by this, please indulge me as I take a tour down memory lane and reach back to my experience on surgical rounds as a medical student 20 years ago. This was a typical morning:

5:00 a.m.
Enter hospital, start seeing patients. Have to wake them up to ask them how they are sleeping.

5:30 a.m.
Update the junior resident on the more complex patients so he won’t look inadequate in front of the chief resident or attending physician.

6:00 a.m.
Begin rounds with surgical team. Walk halls and stop at bedside to talk about patients as if they’re not sitting right there.

6:20 a.m.
Get chewed out by the chief resident for not following up on the red blood cell count on the patient in ICU room 5.

6:25 a.m.
Get chewed out by the chief resident for wasting time following up on the low sodium on the patient in ICU room 6.

6:35 a.m.
Check on patient in ICU 7 with abdominal pain. Attending physician quizzes the team on the 29 known causes of acute pancreatitis.

6:36 a.m.
We run out of ideas on the potential causes of acute pancreatitis. Chief resident looking smug as he brings up “scorpion sting.”

6:45 a.m.
Attending physician tells us he’ll grill us tomorrow on pages 1-200 in our surgery textbook.

6:50 a.m.
Attending physician berates chief resident for how inadequate he is. Starts rant with “When I was a chief resident . . .”

6:53 a.m.
Chief resident berates junior resident for being woefully inadequate. Starts with “When I was a junior resident . . .”

6: 56 a.m.
Junior resident berates medical students for being really woefully inadequate. Starts with “When I was a medical student . . .”

6: 58 a.m.
I berate myself for not signing up for a rotation in the dermatology clinic instead of this month on surgery.

7:00 a.m.
Our final stop is the radiology department. Have healthy, polite and mature discussion on the likely causes of pancreatitis on patient in ICU 7, such as gall stones and alcohol.

Okay, maybe my memory is a little skewed about a typical day on the surgery rotation, but you get the general picture. The key piece of my story comes at the 7:00 a.m. mark. Every day we stopped by the radiology department to briefly present the details of each patient to the radiologist who would then pull up the day’s images and discuss them.

Dr. Jon Bleicher, a radiologist at Midlands Community Hospital in Papillion, Nebraska, recalls such interactions:

“In the golden days physicians made radiology rounds and stopped by the x-ray department as part of their daily routine to review films with us. Doctors took the time to discuss the details of their most difficult, interesting and challenging cases, thus enhancing our ability to provide an interpretation in the proper clinical context. We also gave feedback to the rounding physician so that they were able to order the best imaging test. Being able to discuss cases in person allowed us to avoid the “shotgun” method of radiology evaluation that is so prevalent today.”

I used to really enjoy the input provided by the radiologists as we discussed cases down in their dark offices. They seemed to have more of an “aerial view” of the patient’s condition—the big picture perspective that comes from seeing thousands of scans on patients with similar findings and conditions. “Have you considered . . .” was a common question that frequently led us to broaden our search for a diagnosis or develop more creative options for therapy.

These days we simply order a smattering of tests and wait an hour or so to pull up the terse interpretation on the remote computer screen. Such a system does away with nuance, feedback, and clinical perspective. It reduces the radiology study to a binary system: normal or abnormal.

Of course there is no rule in place that prevents me from walking down to the radiology department to confer with the on-call reader, but I rarely do this unless the case is particularly confusing. The new digital system saves me valuable minutes in my day that I don’t want to spend reviewing x-ray studies for which I already have an interpretation in hand. In this way I’m complicit in the demise of the radiology rounds.

Perhaps we need to initiate a “National-Go-Down-To-The-Radiology-Reading-Room Day” where all rounding physicians make the effort to discuss their patients with the radiologist and for a brief, 24-hour period we can reincarnate radiology rounds. We’d probably find that our patient care improves, our intellectual faculties are stimulated, and our testing becomes more purposeful and streamlined. The next day, of course, we’ll go back to our current system, but our brief foray into rekindling a past tradition might just make us more likely in the future to swing through the reading room.

Of course that sort of thing will chew up precious minutes in a day that could be used for other things like, say, researching the 29 known causes of acute pancreatitis.