A childhood friend of mine who stays in US visited me recently. A small bit of information about him, which I think is relevant to this piece of writing, is that he is not a doctor.  Seated in my drawing room, we were chatting over a bottle of ‘Lager beer’, his favorite. He told me about a recent article that he read in one of the prominent dailies in US, ‘The Washington Post’ perhaps. This article carried a headline, “IS COMPUTED TOMOGRAPHY (CT) CARCINOGENIC?”   He appeared alarmed and intrigued at the same time by the tone of the article which appeared to say that somehow undergoing a CT study is going to give him a cancer. Mind you, he is not a medical professional but an engineer, very intelligent one at that.  Since I am a practicing Radiologist, he thought it fit to raise this issue in front of me. He told me that the lay population in US has become paranoid about contacting cancer due to medical X-Rays.  I tried to reassure him that contacting cancer due to ionizing radiation is a theoretical possibility – but I have not met or heard of any one who has become a victim of cancer after undergoing a diagnostic test such as Computed Tomography. And, I quickly veered the conversation to something less ‘carcinogenic’.

Nevertheless, I kept thinking about it much too often. What if my friend’s fears and rest of the Americans’ fear about X-Rays are not completely baseless?  Is there is a scientific evidence to ‘prove’ that CT can cause cancer?  Am I implanting the seeds of cancer within every young lady who comes to me for a CT scan of the Abdomen and Pelvis? Am I placing at risk of cancer, every child with a seizure disorder who lies down on my CT table for a head scan?  Believe me; I was disturbed.

Chest radiography is the most frequently performed diagnostic examination in the public hospitals and private practices.

Almost 150 million chest X-rays are performed every year in US.

This practice is based on a very simple misbelief and everyone thinks rather naively that :

• If a lesion is present in the lungs, it will show up on the x-ray,
• If a lesion shows up on the x-ray,  it will be detected by the physician,
• If the lesion is detected by the physician, it will be correctly interpreted, and
• If the lesion is interpreted correctly, the right diagnosis will be made.

Large scale studies, spanning over 20 years, have shown that:

• 20 to 30% of radiographs considered as  NORMAL are in fact PATHOLOGICAL (= FALSE NEGATIVES)

• And 1 to 20% of radiographs considered as PATHOLOGICAL are in fact NORMAL (= FALSE POSITIVES)

The perception of pulmonary lesions is influenced by numerous and complex factors.

How do you deal when you discover ‘Incidentalomas’ while doing a scan …be USG, CT or MRI??

Definition of Incidentaloma:

“An incidentally discovered mass or lesion, detected by CT, MRI, or other imaging modality performed for an unrelated reason.”

From    Free Dictionary

Sometime back a patient came for routine USG study of Abdomen while undergoing Master Check Up. The USG picked up a cystic lesion with internal echoes in the pelvis of the Kidney.

One of the most important aspects of practising medicine anywhere in the world is to update the knowledge and skills of clinical medicine. Continuing Professional Development (CPD) is not only updating the knowledge and skills, but also improving teaching, communication and managerial skills.

The practice of radiology changes according to the need of the clinical medicine. As radiologists, we need to be on the edge of the technology to deliver high quality diagnostic and interventional knowledge and skills. It is also about attitudes and values of practising radiology.

In West, CPD is mandatory for all health care professionals. For example, in the UK, all consultants are required to earn 250 CPD points in 5 years by attending various courses and conferences. The Royal College of Radiologists of the UK has published extensive guidelines for the radiologists practising in the UK.

The summer heat had set in and the sun was high in the sky. The clock had just struck noon when the idea to take a quick break flashed across my mind.

I had just finished the morning rush of patients for ultrasound.

Standing up from my chair, I told my secretary of my intention.

Receptionist entered to announce another patient from Germany with renal colic.

Considering his acute problem, I did not deem fit to delay the scan.

As the patient entered ultrasound suite, he glanced at me with a puzzled look.

The nurse draped a sheet on him and I started to take up the transducer when he suddenly sat up.

“Can you do an ultrasound examination?”

I was startled at his question and completely taken aback. Neither did I comprehend the reason for such a question nor could I justify it.

Here I was, having done more than 60,000 scans of all kinds in my career, faced with such a question.

General, Doppler and small parts ultrasound

I have been in some remote areas where people have purchased Doppler machines just to advertise that they produce color pictures. and the patients are impressed and ask for it though the physicians in those areas have not yet felt the need for a Doppler study ‘In contrast there are areas where the physicians are so much aware of Doppler that you have to do one or two vascular Doppler daily. I have worked with a physician who asked for renal Doppler in every case where he wanted to start an ACE inhibitor in a hypertensive patient. He had a good justification for it. In a reasonably good centre a radiologist has to perform at least one of the Doppler study in the areas such as thyroid, carotid, peripheral vessels and at times breast and scrotum. etc. Pediatricians will invariably send a few cases for cranial ultrasound  once in a while. In centers of remote areas ultrasound is the main revenue earner and CT takes the back seat...

Selection of a Centre to work in

Most of these centers require their radiologist to be available 24 hours. Many of them don’t want to give even a day’s off. They may call you for a simple case to do USG even on a Sunday making it as emergency case... On week days you have to work for almost 12 hours Though the salary is good around one lac or more with free accommodation and even free food at times but freedom to move around without informing them is a hurdle and even a great irritant at times. In the beginning as I did not have the experience I worked in 3 centers for two to 3 months but ultimately got fed up and left them as I did not like too much of a disturbance even during night hours A young man may work for a year or two and collect some money so that he can establish his own centre later or until he gets a better job but I had no such compulsions. I would always advise you to go and see the location and working of the centre for a few days and then negotiate and then join if you like.

Subtitle: Knowledge management systems and the universal mind

What  knowledge management systems exist in your organisation?

In our explorations and conversations together we try to seek the difference between the individual mind and the universal mind. As the relation between these two (the individual and universal) gains concrete form, and its own proper shape and appearance, one finds a life of the universal individual.

On "Inevitable Attrition"

Addressing the issue of "inevitable attrition" which Dr.Alok Varshney and Dr.Anuj Mishra raised while commenting on the article "A performance agreement'http://www.iradix.in/515-A-Performance-Agreement.html made me reflect on the nature of knowledge management systems which exist within our medical organisations. Employees must have free-flowing lines of communication between one another and need access to sources of knowledge -both inside and outside the organisation. That knowledge is often the raw material of creative thought.

Some companies have developed elaborate knowledge management systems to capture knowledge, store it, and make it easily available to reuse. These systems help ensure that what was learned by someone in Unit A doesn't have to be learned anew by someone in Unit B. Lee Sage has described DaimlerChrysler's Engineering Books of Knowledge (EBOKs), a knowledge management database containing technical data, lessons learned, and best practices that is made available to the company's engineering community. The purpose of the EBOKs, according to Sage, is to capture the expert knowledge of technical employees and use it to improve engineering productivity, speed new product development, and avoid repeating past mistakes. Consulting and tax accounting companies use knowledge management systems in similar ways (1).

An editorial in The British journal of radiology in the late eighties had rightly predicted that by the   year 2000 there would be a world wide shortage of radiologists by 50 percent. And perhaps this presumption had been the concern of only the radiology community and the clinicians who depended, on radiology services to what extent only they knew or perhaps know now, never gave radiology the respect due to it inspite of the awe -inspiring entry of Ultrasound, CT and MRI enhancing the status of radiology to the present level that the brightest of the medical students are getting attracted towards the field.

About 10 years back a very senior American radiologist remarked during an IRIA conference that the imaging technology about to come will astound you and a time will come when clinicians won’t be able to write a prescription without our help. Since then and now I am not aware what changes have taken place in the minds of the clinicians as I still perceive their usual arrogance but when they come to the point of shaking hands their attitude does softens a bit. It is not our ability to handle an advanced imaging equipment that has earned their closeness but the money associated with it as they pay the same or even more attention to a rich patient of theirs oblivious of the radiologist’s presence at times...

How easy or how difficult is to run a diagnostic center?? Any idea??

Everybody says that Radiologists are the luckiest among the Medical Profession and it is assumed by our Non radiologist friends that Radiologists make a lot of money without much sweat  whether working for somebody or running own diagnostic center.  .Nothing is far from the truth.

Some of the Radiologists as soon as they successfully complete their course may want to start independent diagnostic center.

The center can just have one Ultrasound machine initially with two receptionists and two helpers in the beginning

Not many problems initially faced by the radiologist and running of the center is a smooth affair.

Once the radiologist starts thinking of expansion either due to severe competition going on in the market or because of customers demanding... add on facilities…….. the problems start one by one.

So as the idea of starting a full fledged center crops up…. more and more machinery are added besides the Ultrasound machine.( the machines include, Digital  xray,CT,MRI,,Complete lab equipments, Mammogram, PFT,EEG ,Nerve conduction test ,Endoscopy etc.)

Present day setting up of a diagnostic center is not as simple as one may think .Gone are the days when one was very comfortable by enjoying a decent profit...

In broad terms, diagnostic imaging offers the clinical investigator two principal types of information. Most imaging techniques provide information on macrosopic structure, by revealing the anatomy of organs and the morphology of lesions. A second major focus of imaging techniques is the circulatory system, in particular the vascularity of tissues and their perfusion by blood. Future diagnostic imaging modalities, currently used only in research settings, can provide information at the molecular level, such as the concentration of metabolites and the tissue density of proteins (e.g. receptors, enzymes).

Ultrasound (USG) provides information on both macroscopic structure and blood circulation. The capabilities of ultrasound can be improved and expanded by the use of a contrast agent, which does much more than simply improve the signal-to-noise ratio or compensate for inadequate instrumentation!

The role of contrast-enhanced ultrasound (CEUS) in liver imaging is very well established. However, its application in other organs is still controversial.

Herein I will describe a series of clinical examples to illustrate some of the varied uses of contrast-enhanced ultrasound beyond the common application in the study of focal liver lesions.