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Editorials |
1 From the Department of Radiology, Massachusetts General Hospital, MZ-FND 216, Box 9657, 14 Fruit St, Boston, MA 02114. Received January 30, 2007; final version accepted January 31. Address correspondence to the author (e-mail: thrall.james{at}mgh.harvard.edu).
Dr Wilner offers reflective, sobering, and poignant observations from his 25 years of practice (1). We should reflect along with him because it is likely that most of us, especially those who have practiced for a similar amount of time, have experienced many of the same issues that he has described and have entertained the same thoughts so succinctly captured in his narrative.
Dr Wilner beautifully captures the best traditions of medicine: full attention to the patient, listening, hands-on examination, and learning. His story of diagnosing trochanteric bursitis and a rib fracture by means of simple personal interaction with the respective patients illustrates these traditions, and Dr Wilner reminds us that radiologists are doctors, too. We should savor these stories and take heed of Dr Wilner's thesis; otherwise, the practice of medicine risks losing its soul to the machines that are relentlessly reshaping it. Radiologists know better than physicians in any other discipline about the challenging issues that arise at the interface where the healing arts meet medical science; however, we also know from Dr Wilner's story that patients benefit the most when both the art and the science of medicine are brought to bear in the right measure.
Dr Wilner highlights a troubling phenomenon that is creeping into the dialog between patients and physicians: demands by patients for treatments that are not indicated for them. We are seeing this more and more as a negative counterpoint to the positive trend of patients becoming more informed, often through excursions on the Internet or direct-to-consumer advertising about health products and services.
We welcome informed patients and are dedicated to helping everyone obtain the information they need to understand their care, but physicians will be increasingly challenged in two ways: The first is the patient with misinformation from incorrect or deliberately misleading information sources, especially Internet-based sources. The second is the entitled patient who demands specific procedures or drugs through the mistaken impression that he or she will benefit from them. A concrete example from our health system is the frequent demand for magnetic resonance (MR) imaging for musculoskeletal complaints that fall outside the appropriate guidelines. This is not a surprise since it seems that almost every football broadcast includes a discussion about a player undergoing an MR examination. The subtleties of costs and benefits to the health care system are lost on patients with acute symptoms who want everything to be taken care of immediately, just like it happens on television. Physicians will need to develop new strategies to deal with this behavior, since it is likely to increase as the baby-boom generation reaches its high health care consumption years.
Dr Wilner reminds us of the power of physician-to-physician consultation that we might include in a broader category of communication. How ironic that in an age so rich in new methods of communicating, actually accomplishing the task person-to-person seems ever more difficult. It has always struck me that the more "efficient" a means of communication, the more likely we lose context and nuance. The result of absent or reduced communication before imaging procedures are ordered is the performance of unnecessary or incorrect examinations. The result of poor communication after imaging is potential delay and confusion in the care process.
While mostly celebrating tradition, Dr Wilner opens the door to a new practice model: more direct communication between radiologists and patients about the results of their examinations. Since the work product of the radiologist is the report and no medical value is derived from the report until it is actionable, the issue of communicating the report to someone who can take action on behalf of the patient is absolutely central to our specialty. We have always assumed that the person to take action would be the referring physician; however, in light of Dr Wilner's other comments about the modus operandi of medical practitioners today and the frequent difficulty in contacting them, perhaps the patient is the more logical target for the transmission of his or her own information, at least in parallel with traditional information flow.
Historically, many referring physicians have sought to enjoin radiologists from discussing results of imaging examinations and their implications with patients. Most radiologists were and are just as happy to go along with this order and not encumber their time or become mired in complex care scenarios. However, in the time-compressed world in which we live, completing the cycle from radiologist to referring physician to patient may not meet the needs and expectations of patients anxious to learn their fates and worried about moving on to the next step in their care. If radiologists begin to communicate more directly with patients, they need to tread a fine line between facilitating the care process and overstepping their roles and relationships.
So, is it all gloom and doom or are there bright spots on the horizon? How should we look at new practice models, and how do we adapt? How do we interact with colleagues who have turned at right angles from long-honored concepts of professionalism? How do we remain steadfast to our immutable commitment to our patients in the face of the hurricane-force winds of change?
In the end, it always seems to come down to balance. In our situation, this means incorporating the best of what is new with the best of what is old. The best of what is new is the ability to do astonishing things with new technology to improve diagnosis and therapy while also improving outcomes and lowering risks.
The story of appendicitis and imaging is an exemplar for this paradigm. Before imaging was used to diagnose appendicitis, physicians never were able to move past about 80% in the accuracy of preoperative diagnoses, and accuracy was even lower in children younger than 12 years (2). This meant that a substantial percentage of people who went to the operating room with a preoperative diagnosis of appendicitis actually had something else, and a substantial number of these unfortunate patients would not have required surgery had the correct diagnosis been known. Other patients who should have been taken to the operating room immediately underwent periods of observation (3), often while they were experiencing pain.
When computed tomography (CT) is applied in the diagnosis for patients suspected of having appendicitis, the false-positive rate can be reduced to 4% or less (3–5), and the observation period usually is eliminated. In many patients shown not to have appendicitis, other diagnoses are established (3,5), some of which require medical or surgical treatment that can then be applied promptly and efficiently. Dr Wilner would ask only that the referring physician examine the patient and listen carefully to his or her history before referring him or her for CT and perhaps consult him for the latest thinking on the subject.
The best of what is old is professionalism: the entire complex gamut of professional behavior, including caring, ethics, communication, and empathy. Today, little remains of medical science from hundreds of years ago, but the values of healers remain unchanged from the days of Hippocrates. We do not need to invent new concepts of professionalism, but we do need to remind our colleagues and ourselves every day that professionalism is at the very heart of what we do and who we are. Professionalism must be our constant companion.
Dr Wilner has alerted us to a great opportunity for all of us as physicians and radiologists. Radiology has led the transformation of medicine into the digital and molecular age, and no specialty has made more technologic progress; now, let us make sure that we lead the rest of medicine in not changing something even more important—what it means to be a doctor, to be a medical professional. Let us listen to Dr Wilner's pleas and, through our own professionalism and its influence on others, make the health care system better.
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FOOTNOTES |
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See also the editorial by Wilner in this issue.
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