iRADiX

'Man was born free, and he is everywhere in chains'

The Social Contract

Jean Jacques Rousseau(1)

In the previous entry we looked at some “high resolution” issues.

It has been a heartening fortnight for IRADIX with Dr. Alok and Dr. Sridhar using their energies and expertise to enlighten us with Full-fledged articles. Alok’s article on Cut Practice http://www.iradix.in/489-Cut-practice.html and the discussions following it reminded me of the “Book of the world” from which Rousseau told he will educate a simple and natural child for life in a world from which social man is estranged.

Coming back to the topic of quality control, within a hospital there are many departments which have sonology units. This issue was examined in the Blog Self Referrals in which we also looked into the meaning of Quackery and how Vendors have identified their potential market within non-radiology departments to sell imaging equipment. Quackery is defined as a person posing to having knowledge-training of a particular field and practicing it, while not having had any formal training, qualification or experience in it.

See blog: http://www.iradix.in/282-Self-Referrals.html

Can the technical review meeting have a look into this?

“I have seen many of his mistakes”: The Hepatologist and the Sonologist

This remark about a fellow radiologist by the great hepatologist who knows how to see the liver ‘better’ than any radiologist made the radiologist alert. If he is talking like that about one radiologist, he will be talking in the same vein about you too behind your back. One has to be careful.

“I personally review all my cases by ultrasound” he remarked one day, in the same ‘smarter-than-you’ haughty tone.

“He gets a percentage for doing ‘ironing-with-the-probe’ ” The radiologist keeps pointing that out in management meetings.

This has led to a lot of lobbying from the opposite side, which has made the radiologist modify tactics, or to use sonography parlance-a bit of angle correction, gain and velocity range.

The Hepatologist friend who does not know anything about these terms does better ultrasound-doppler than the Radiology Head of an Organ Transplant unit.

Lesser radiologists do not even qualify for a comparison.

Snowstorms and Echogenicity.

One can start going to the sonology clinics of the esteemed ‘experts’ to see what they are doing with the probes.

The getting of a proper image from the “snowstorm” which he usually is trying to navigate through requires an adjustment of gains. The surrounding grey ‘snowstorm’ corresponds to the hepatic parenchyma, which is traversed by hepatic vessels. How can one quickly work out which structures in the image appear bright and which are dark? The key lines in the concept of echogenicity. What does the Term “echogenicity” mean? Tissues or organs with many intrinsic impedance jumps produce many echoes and appear “echogenic” =bright. In contrast tissue and organs with few impedance jumps appear ‘hypoechoic’=dark. (2)

What do physicians (even self styled hepatologists) mean when they refer to a dense liver? It reflects either sloppy language or ignorance. In contrast to radiographic methods, which visualize physical densities, sonography visualizes differences in sound velocities (impedance jumps) which are unrelated to physical densities.

The retired Head of Medicine: Understanding the liver using PRF

Many gastroenterology units have their own sonology equipment.

“Do you think you know the liver better than me” the retired head of Medicine who had just set up his clinic in a posh locality in the capital asked the radiologist. He had bought an ultrasound-doppler unit too. "I have been doing ultrasound for over 20 years"

The atmosphere in the room became uneasy as the former student, who as an MBBS student had attended the lectures of his former Medicine HOD just kept quiet, offering just a subtle smile for an answer. (and some memories of what it is to be a trained radiologist.. A trained radiologist can see an image in a way even the most experienced clinician cannot see. Blog: www.iradix.in/284-Pedagogy.html)

The HOD repeated the question. The smile continued, half-polite and half-mocking now.

“No answer?” the professor said.

“What about evaluating vasculature?” the radiologist finally broke the uneasy silence.

In the imaging of patients with chronic liver disease or portal hypertension or who have undergone liver transplantation or surgery, accurate evaluation of the hepatic vasculature is usually necessary. An informed choice of transducer and scanning techniques is important in the evaluation of the liver vasculature. There are essential technical and operator-dependent parameters that can be modified to optimize the performance and interpretation of Doppler ultrasound of the liver. Some of these parameters influence both the color and spectral components of the Doppler US examination (baseline, velocity scale, wall filters, inversion of flow), some are specific for the spectral Doppler component (angle correction, spectral gain, gate size and position), and some are specific for the color Doppler component (color gain, color bar, color box or overlay, color velocity scale, color priority) (3)

Once the radiologist illustrated some of the above points, the retired HOD did not ask him this ‘loaded-question’ again and started referring chronic liver disease cases to him.

It is not always that straight: Remembering Rousseau’s Emile

The above two examples, using the liver as a focus, illustrate some of the ways in which we can highlight the technically complex aspects of image acquisition with the ‘self-styled-experts’ and the management parties who often remark...

“it just takes five minutes to make a radiology report.”

See blog: http://www.iradix.in/281-Instant-Reporting.html

These issues of quality control, high resolution imagery to vascular issues also make one reflect on the estrangement of the ‘social man’ as described by Rousseau and the nature of common sense, sensation and reflection and formation of ideas as illustrated by the ideas of Italian philosopher Giambattista Vico which we touched upon in the previous blog Get me a High Resolution Image.

Rousseau’s “Emile” was removed from society at large to a little society inhabited only by the child and his tutor. Social elements enter the little society through the tutor’s knowledge when the tutor thinks Emile can learn something from them. Rousseau’s aim throughout is to show how a natural education, unlike the artificial and formal education of society, enables Emile to become social, moral and rational while remaining true to his original nature. Because Emile is educated to be a man, not a priest, a soldier, or an attorney, he will be able to do what is needed in any situation.

Rousseau’s Emile was published in 1762. There was no branch of Radiology then. Technology has increased our ways of acquiring sensations manifold. Finance capital has changed the way the world is organized.

Going by the varied experiences ,adventures and dilemmas which a radiologist may face in a working-day while navigating through the maze of different specialties which refer cases or the ‘business-models’ which generate cut practices, insurance, company empanelment and embassy recognition issues, it would be interesting to reflect on what Rousseau’s Emile would be educated on in today’s world.

Notes and suggested further reading:

1. Michele Erina Doyle and Mark K. Smith (2007) ‘Jean-Jacques Rousseau on education’, the encyclopaedia of informal education, http://www.infed.org/thinkers/et-rous.htm
2. Mathis Hofer: Ultrasound teaching Manual. The basics of performing and interpreting ultrasound scans. Second edition. Page 7.
   Apart from Clark’s Radiography, one can arm one’s “fort” with such technical publications on CT, Ultrasound, MRI techniques and images optimization which can be cited and develop a rational baseline of discussion.
   In foreign settings I found this particularly useful as there are ‘experts’ who just come in without any references and start speaking the “gospel truths….It is done like this in France and Germany…”
3. Kruskal JB, Newman PA, Laurie G: Optimizing Doppler and Color Flow US: Application of Hepatic Sonography. Radiographics 2004;24:657-675

(have been myself trying to improve on this issue through reading technical publications...it is a long journey)