Raju: Wow, look how time flies... Just yesterday we had joined radiology PG and now we are just about to finish the residency. Hey guys, what are your future plans?

Farhan: Man, I think Radiology future is in the dark … Why did I do radiology in the first place beats me. I was ranked 7^th in PG entrance exam, I could have chosen any medical field… I think I made a big mistake….

Raju: Are you nuts? Radiology is the coolest, the most glamorous branch. Some people pay 2 crores for a radiology PG. Where else would you get to sit in an AC room throughout the day in this hot weather? All we have to do is write a bunch of reports and then we are free. To tell you frankly the reporting isn’t that boring, you do get to see interesting cases once in a while. Like today we saw a case of KLMNO disease…What do you say Rancho?

Rancho: All is well, all is well….

Role of Apology in Practice

One of the things the average doctor doesn’t have time to do is

catch up with the things he didn’t learn in school, and one of the

things he didn’t learn in school is the nature of the human society,

its purpose, its history, and its needs….If medicine is necessarily

a mystery to the average man, nearly everything else is necessarily

a mystery to the average doctor.

Milton Mayer

“Would you accept an apology” the senior doctor asked the relative.

Later, he asked the resident whether he would like to apologize.

The three of them then met and a face-to-face discussion led to restoration of harmony.

“We are all human” the relative said after it was all over, accepting the factthat mistakes can occur.

“Ring him up personally and explain how and why you felt that one of the prominent collaterals of the ECA was the ICA. Otherwise in future, he will lose faith in your reports.”

One of my mentors told me to explain to a senior Neurologist how I had reported on the ICA as narrowed on MR Angiography when the Doppler report had shown it to be completely occluded.

He could have done it himself, and ticked off the junior. He knew the senior Neurologist very well. But he left it to me to do this difficult part of the communication which was also a multilayered lesson.

All of us have been shaped by our seniors who have acted as our mentors, shaping our journeys and career choices. Mentoring is an informal role, but is probably more vital than the formal structural hierarchy in organizations. In Blog “Part Time” I had talked about mentors who in their own ways –through the “Fort Analogy” and “Piecemeal explanations” helped understand the maze of modern health care.

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How independent can one be in a modern technology driven specialty branch dependent on referring physicians?

Systems and communities of practice

In the previous blog we had examined some practice options (Part Time?)

As Dr. Sridhar rightly pointed out that we are a referral dependent specialty and in his interact on Forum of Super specialty in Radiology has observed that one really does not often meet radiologists who are practicing as independent super specialists. We meet Neurologists, Cardiologists..but…super specialist radiologists?

In Blog End of Individual Goliaths we had examined how if one has to hold ground one has to be part of some system of practice.

Does the person who is working “For Himself” really work alone or are they part of several practices.

One surgeon friend did not want to initially invest on costly radiology equipment as he had invested in operation theatre and Intensive care units. He asked his radiology friend to invest and set up the radiology department.

“I am a man of limited means and you can use your real estate to become independent any time, once the initial loss making ‘teething’ period is over” the radiologist replied frankly.

“Is there anything known as ‘Part Time’?”

Déjà vu

As I saw my friend debate into having one’s own equipment soon after having joined a private hospital, I had a sense of Déjà vu.

They say, hindsight is a wonderful thing. Here I present some of the private practice options, overlaps and paths.

These are not meant to be an advocacy of any one path, but an attempt to show the different trends; and as an enquiry into what could possibly suit us and hopefully will get refined after contributions from our commentators.

A Fort

The senior surgeon called up the young radiologist and asked him to join the ‘fort’.

“There are many such diagnostic centres. Many more will open up in the next few years. This hospital is like a fort. And once you are within it, it is up to you, to see how you fit in, whether you are in the back room or in the centre of things.”

This Fort analogy to private medical institutions, given by the surgeon, serves as a reference to measure up which type of practice one does and how being part of these institutions will shape future choices and horizons.

“With all our limitations, we are an institution” the surgeon continued.

Does your organization have a developed logic to guide radiology test ordering?

How does one play this complex game? Are there rules agreed upon before hand?
Or is it a power-might decides milieu in which you work?

Differing Milieus
Some teaching hospital Radiology heads and professors command so much authority that they can tell the clinical departments-
“We will do it this way, or you can get it done elsewhere!”.

On the other end of the spectrum is the practicing radiologist who has to comply by the whims of “big-referring-clinicians” who are in tandem with the finance owners.

How much rational choice does one have, in either milieu? From cheering the “Radiology Generals” to (self) pitying the “Foot soldiers” we have a wide spectrum.

In the middle of this, the right of information of the patient probably got almost forgotten.

What is a life without problems?

Idealists to pragmatists
My fellow radiologist was pleading to the director to be released as he wanted to go back to India. “My father is not well,” he said. The director who had administrative powers to withhold his exit from the country answered in a clichéd manner-“Everyone has problems”, not wanting to go into the specifics.

Earlier I was more vocal in personal cases, but now, having taught by many colleagues how dynamics and motivations change, I am a bit reserved and pragmatic.

As department or section incharge, one has to have a roster and someone will have to man the C-arm when the surgeon comes. No excuses.

The Roster
My chief resident was one of the first organizers I recall who was tough enough to withstand all pressures, personal attacks, back biting and would stick to the roster.

It is not only a case of Egos. Missed diagnosis can later land in courts.

Even not having suggested a particular differential which later proved right on follow-up or staging which was completed after inputs from different knowledge sources can be used by lawyers who want to prove their case. This is a world of Half-truths.

When there is no clear written policy, power relations tend to decide priorities.

 

Buy a tie?

One day a radiologist saw his friend come to the centre and discussing something deeply with the partner-radiologist.

 

What is he doing here?  Knowing the background of their relation and to put it diplomatically, things were not the same as before between them, it was rather unexpected to have him in the centre which he toiled to establish.

 

The Stranger, Albert Camus
Existentialist Novelist

Alienation of people from aspects of ‘human nature' makes them strangers to their own selves.

 

Is it a degradation?

A senior radiologist asked this question to his junior, one evening as they were finishing off the reports. The senior had been shifting uneasily in his chair which made the junior sense that there was something weighing on his mind. The question did not take the junior by surprise as he had sensed the uneasiness in the uneven relation between the two seniors who were once contemporaries in a leading national institute.

 

Is there hope left for humanity?

Patients have become consumers. Doctors are service providers. If we blind ourselves to the business aspects of healthcare, then it is only at our own peril. When the insurance companies come, they need certain criteria to be met before your hospital is given the contract. When the maintenance contracts are signed, there are cold blooded calculations to be made by large transnational companies on the other side.

 

No effective modern Radiology manager can be blind to these realities. No idealism, only social and production material relations seem to be left.