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Department of Radiology, Schneider Children's Hospital, 270-05 76th Avenue, New Hyde Park, NY 11042
e-mail: john.leonidas{at}verizon.net

	Editor:

TOP Editor: References

 
For almost 40 years now, a major part of my life has been sitting (and occasionally standing) in front of images of the human body. Over the years, the form of presentation of the images has changed from film hard copy (formally referred to as radiographs or roentgenograms, but commonly known as "plain x-rays") to the computer-generated images of today.

As technology advanced there was an explosion of information. And yet it is the same human brain that is now asked to process the seemingly infinite sources of data present in today's multiple planes of cross-sectional images such as computed tomographic (CT) scans or magnetic resonance (MR) images. This kind of work needs a level of mental concentration that may not be easily comprehended by our referring clinical colleagues. The rapid pace of interpreting images from a variety of such procedures causes fatigue. Consider as an example a pediatrician who goes over the history and performs a physical examination of a young girl with an acute onset of abdominal pain. The pediatrician's time is spent thinking about the specifics of just this patient, including the differential diagnosis and so on. On the other hand, a radiologist may spend an approximately equal length of time trying to interpret as many as 10 or more imaging studies in patients with a wide variety of clinical presentations, from many anatomic sites, and usually with more than one type of examination (eg, radiography, ultrasonography, and CT).

The task of the radiologist becomes more demanding because there are constant interruptions. Exchange of information between radiologists and referring clinicians is very useful, but why not do so without interrupting the train of thought of the former? It would be unthinkable, for instance, for a nephrologist to suddenly barge into a dermatologist's office to show a newly discovered skin rash while the dermatologist is examining a patient! The proper way would be a referral.

Radiologists are treated differently. Almost always there is at least one referring clinician (and more often more than one, forming a line) ready to interrupt the radiologist, occasionally even in mid-sentence of a report so as to get a "reading." Sometimes the referring clinician will wait, but even then the psychological pressure of having someone breathing on their necks makes most radiologists give in. At times in the middle of this, a second referring clinician will start discussing his or her case, in what I call a "double interruption" or "interrupting the interruption."

I recognize the need for urgent communication with the radiologist (although I have had interruptions for questions about a bone age determination!). Nevertheless, I believe that a proper time for consultation is essential, even if it is informal and at frequent intervals. In this manner, the often-heard frightening question—"Which patient are we talking about now?"—will not be heard again.

Response

Department of Radiology, Children's Hospital, 300 Longwood Avenue, Boston, MA 02115
e-mail: george.taylor{at}childrens.harvard.edu

Dr Leonidas echoes a common complaint by clinical radiologists all over the globe. Interruptions can be frustrating, time-consuming, and disruptive. They can also distract us from the focus required to review and synthesize all of the visual information presented to us. Mack and Rock (1) coined the term inattentional blindness to describe our inability to perceive unexpected objects directly in our visual field when our attention is diverted to another object or task. In a study of this phenomenon, Simons and Chabris (2) presented observers a short video clip showing two teams of three players each, in which one team wore white shirts and the other team wore black shirts. The players passed a basketball to each other and performed other physical actions, as well. In the middle of the video clip, one of two unexpected events was introduced. In the first instance, a tall woman holding an umbrella walked across the scene, and in the second, a shorter woman wearing a gorilla costume walked across in similar fashion. The subjects were asked to watch the video and focus on counting the number of times the ball was passed. The unexpected "walk-throughs" were missed by the observers between 36% and 55% of the time, related to their focus on the task of counting basketball passes. The effect of repeated interruption serves as a similar potential detractor to the radiologist's ability to detect unexpected findings on an imaging study.

Unfortunately, changing human behavior can be exceedingly difficult, and it is unlikely that referring clinicians will stop interrupting radiologists. Advocacy for their patients and increasing demands on their time are two strong cultural traditions and values that will ensure that this practice remains in place. In addition, dissuading referring clinicians from coming to consult with us is not something we should undertake.

How then are we to preserve our own ethical and professional responsibilities to the patients whose images we are entrusted to interpret? Here are some potential solutions to consider:

1. Institute a radiology consultant of the day or specific times for consultation. In our department, we have established specific times for each clinical team to come to the department to review imaging studies of their patients. We assign a staff radiologist in the main reading room whose responsibility it is to lead ward rounds and provide consults for other clinicians. This has allowed us the time to adequately review images with fewer unscheduled interruptions.

2. Close the door—at least for a short time while you finish reviewing the complex MR imaging study in front of you. Our reading room has an open public section, as well as several peripheral reading areas with doors that can be closed. Although we discourage long reading sessions in isolation, separating of production (eg, case review and dictation) from consultation can be an effective strategy to limit interruptions.

3. Finish what you are doing, then engage the clinicians. This approach can be very effective, but it takes discipline and a bit of thick skin to carry out. Most clinicians, if asked, will come back a bit later or will wait until the radiologist is done.

One final suggestion is to try not to take interruptions personally. The pace of medicine has intensified dramatically over the past decade, and everyone is trying to accomplish more in less time.

	References

TOP Editor: References

 

1. Mack A, Rock I. Inattentional blindness. Cambridge, Mass: MIT Press, 1998.
2. Simons DJ, Chabris CF. Gorillas in our midst: sustained inattentional blindness for dynamic events. Perception 1999;28:1059–1074.[CrossRef][Medline]

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