Prof. Philip Gishen
Prof. Philip Gishen (Above)
Director of Imaging
Director of Imaging
Dr Domonic Blunt
Director of Training
London, United Kingdom
The problems faced by the National Health System (NHS) in the United Kingdom, are well known.Recent studies predict an annual deficit of nearly £7bn in 2010, which has worsened financial pressure to cut spending. Among the negative effects, are postponed operations, cuts to training expenditure and frozen plans for the recruitment and retention of health workers in the NHS. Radiology has not been immune to these political shortfalls.
This article delves into the issues surrounding the politics that threaten the future of our profession. Rather than shifting piles of film to radiographers and ignoring the fragmentation of the profession, PACS and voice recognition technology offer a concrete way to consolidate departmental performance, circumvent the handover of our profession to radiographers and meet the needs of our customers.
In an Ideal World…
What do our customers, namely referring clinicians, and, by proxy, also the government of the day, require from us? Ideally, they would like every imaging investigation performed immediately and seamlessly, in a beautiful environment and with respect and dignity to the patient. They also want studies reported immediately.
They want them interpreted by someone they trust, who understands the clinical question and is aware of any previous medical history, with no delay, whilst being available for discussion if there are any queries. Patients would like this for free. Some doctors would even like the radiologists to pay money to them when they refer a patient. Imaging associations set stringent standards they require radiologists to work to, while the government doesn’t care who reports cases, or to what standards, as long as their statistics look good.
Old Versus New: How We did it
Four years ago, one of my departments still used film, leading to many problems. We reported about 60% of our plain films and had a four-week delay in report turnaround. We had the usual complaints due to unreported films and often could not report scans, because the clinicians had removed films from the department. Comparison with old films proved tricky; our film store was on another floor, and though we tried to pre-fetch packets, the retrieval rate was under 50%. We were constantly answering the phone to give ‘a quick verbal report’ on a scan which had been reported but was not yet available on the radiology and hospital systems.
Four years later, we report all exams, including casualty films, inpatients and outpatients on the same day and the report is available on the hospital information system the same day. We do not run hot reporting because everything is hot reported. Our improved training scheme trains 32 registrars and we train them better than before.
We have done all this in the face of a relentless increase in the complexity of the work carried out by the department and a painful cost-improvement programme. How have we done this? Greater number of radiologists? Radiographer reporting? No. PACS and voice recognition dictation systems were installed to our specifications, to improve workflow and eliminate delay from the reporting and transcription end of the process.
This was accompanied by timetabling on an hourly basis, sharing work fairly, reorganisation of on-call services so that those on-call could do the procedures and were paid extra, whilst those not on-call chose ‘lifestyle’ instead, elongating the routine departmental working time and creating a comfortable reporting environment.
Dealing with the Shortage of Radiologists
Despite complaints that there is a shortage of radiologists, we are in fact training more and more radiologists. One hospital close to mine used to have an advertisement in the British medical journal almost every month for a radiologist, with no takers. It recently appointed someone, from a field of eight applicants. Not only this, but in the future, British radiologists will have even less of a toehold, since teleradiology will mean that radiologists will be logging into your hospital PACS system and the electronic patient record from virtual sweatshops across the globe.
Radiographer reporting is clearly not the answer. Radiology is a very demanding science. I don’t know what a routine study is! I know that outpa tient brain scans have a high rate of normality or insignificant findings, the same for lumbar spine MRI and for many plain films. However, I take pride in spotting the unexpected, and am mortified when I miss it. Spending two years studying real anatomy at medical school, and five years in front-line clinical specialties before I began in radiology, has made me better at complicated cases, because I still look at the ‘routine’ the ‘normal’ or ‘unlikely to be abnormal’ cases.
The Value of a Well-Trained Radiologist
It may be uncommon that a study throws up something unexpected, but I should be able to spot it, drawing on wide experience of what any body part looks like. It is utter rubbish to think it helps us not to have to look at these so-called routine studies. Unless we are much, much better than our referrers, we will lose our specialty. They will buy the equipment and control the patients. Any move which helps us towards mediocrity must be avoided.
Finally, any argument based on unit activity and unit cost only plays into the hands of a government terrified of anything it cannot measure and turn into electoral success. We must rise above this. They fight hard to remove our professionalism, dumb down our training, and insult our skills: we must not stoop to their levels.