A critic is a man who knows the way but can’t drive the car.

Kenneth Tynan

The technician came to me looking harassed. He had a cervical spine lateral x-ray view film with him.

“Do you feel it is alright?” he breathed out in exasperation.

The whole of the cervical spine from atlanto-occipital joints to the top of the first thoracic vertebra was included. The mandible or occipital bones were not obscuring any part of the upper vertebrae. Soft tissues of the neck were included adequately. The contrast produced densities were sufficient to demonstrate soft tissue and bony detail.

I queried the technician as to what the issue was.

It was our Neurosurgeon (again) who had wanted to see the films in his OPD (without radiologist’s report) and then declared to the relatives that they were inadequate and sent them back to get them done properly.

This particular gentleman is not amenable to any discussion as he knows everything (from Germany) but cannot tell what are the criteria for a proper cervical spine lateral view. Thankfully we have the latest edition of Clark’s Positioning in Radiography to show these international experts what criteria we need to fulfill when taking a particular view. Having worked in a place where there are ‘experts’ from different universities, some of them pretty aggressive, over the years, I have armed our department with many lists of criteria, guidelines and best-practice evidence.

The state of our medical practice as has been illustrated in the previous blogs and the comments following speaks for itself.

Can there be Science without conscience? How do we work towards preservation of the patient-physician relationship in this milieu?

Indiscrete Jewels

There could be no better hook upon which to hang a contemplation of our milieu of practice than the fictional dream recounted by Denis Diderot (1) in his novel Les bijoux Indiscrets (1748;The Indiscrete Jewels). In this work Diderot describes a building without foundations, whose pillars, among which deformed and crippled men loiter about, soar upwards into swirling mists. The building is the Palace of Hypothesis and the old men are theologians and metaphysicians. Then an energetic little child appears, and as he approaches the building he grows into a giant; his name is Experiment, and when he arrives at the Palace of Hypothesis he gives it a mighty blow which smashes it into ruins. Thus science shatters the systems of Theology.

Evidence based work

A search for common values in a rational scientific context centered on preserving the patient-physician relationship can be found in the approach of “Evidence Based Radiology”(EBR).Why this debate and discussion, some friends may ask. It is in ‘enlightened self-interest’ to prevent burn-out, lack of interest in work as one finds the key decisions relating to one’s practice slipping out of one’s hands. Evidence based Radiology is a method inspired from the analytic process. It emphasizes autonomous reflection, systematic identification of roles, motives, and consequences of current actions and organizations, clarification of aims and means; selection of principles and values, and equilibrium, application and validation. This method entails constant vigilance and repeated revisions, but the allowance of time to think about ethical matters and decrease confusion and moral perplexity. The result is a stronger moral personal identity and a brighter horizon for a satisfying professional life. ”. (2, 3)

Having introduced the topic in previous article, we shall try to examine specific situations and try to evolve a common body of knowledge. In this I will deal with some specific situations which are within our direct “Circle of Influence” in our departmental settings and also try to name possible areas of concern which require wider inputs.

Need for setting up mechanisms

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Of Cones and Numbers-Conversations with a Nephrologist

What about a good ultrasound in the hands of a skilled practitioner who knows something about the pathology and different manifestations? I asked a nephrologist who has recently returned from his many years in a Western university and was quizzing me regarding role of multislice spiral CT and  MRI in renal disease.

 

A Small notebook

Sometimes, lost in the maze of high sounding technology we tend to get carried away. This also pertains to the fact that many who are not conversant with the technology get overawed in front of persons who seem to be talking about very high end things.

 

As we celebrate the 200^th birth year of Charles Darwin , one of the pillars of modern science a leading Evolutionary biologist said in an interview on this Father Figure who has shone the light for many, that one of the most important aspect of Darwin's work was recording things in a notebook.

 

Ever since the initial post mortem description by Chiari in 1891 of the group

Of malformations that bears his name, it seems there have always been more questions

On this subject than answers.

....Ball and Crone

Conversations with Dr.Abdul Adim Ben Ashor, (AABA) Consultant Neurosurgeon

Trained in Christian Albrecht University, Kiel, Schleswig-Holstein, Germany

The support specialties are the eyes and physicians of the surgeons. This was taught to me by my father, a Cardiac anesthetist. Finding myself in a support specialty (Radiology) I have found this lesson useful over the years, if one has to retain relevance one has to be the eyes and physicians of the surgeons, and guide them through their adventures and ‘misadventures'.

The way one looks at the posterior fossa and base of skull, is one of the distinguishing features between a person who knows how to read a MRI and the ones who just pass off a few changes in the normal template.

 

From passionate reformers, ethical scientist torch bearers, to grumbling egoists, and degenerate commission seekers, they come in all shades of grey.

Here are some conversations with Neurosurgeons.

 

Does a poor man not have neurological illness?

He was the best singer of us all. The strains of the sitar played by him on the 12th floor as we would feel the breeze flow from the Arabian Sea and watch Parel and Worli Sea face are still with us-deep inside. We would go to Gloria restaurant in the evenings and have Mangalorian food while he confided the nuances of his courtship. Gloria also serves liquor on the sly. He would take us through the Ragas and also gave us a window into the social reform movements of Maharashtra in the tradition of Jyotiba Phule and Bhimrao Ambedkar.

 

Conversations with General Surgeons-Our Modern day Socrates

Some of my closest doctor friends and teachers have been General Surgeons.

 

 

"A good surgeon can be a good physician, but a good physician cannot be a good surgeon" my Head of Surgery during MBBS days used to often repeat this aphorism on his weekly rounds. We MBBS students used to think he was "God" and were always overawed in his presence.

 

 

Conversations with a Neurologist

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What do you think of the referral slips sent by clinicians?

As radiologists, we come to know the depth of the referring clinicians by reading their referral request forms. There are some clinicians who will not even write a history. There are some who will write a few words and that is it. Some who will write detailed notes. Some who will ask specific questions on what they are looking for.

 

          "I never miss a diagnosis on Ultrasound and even my director calls me when he has to take a second opinion" a gastroenterologist told the radiologist in a haughty self-assured tone.

  

           "He did a 2 week course of ultrasound and a 4 week course on endoscopy from Vienna and then returned to become a Consultant. Before that, we used to share the General Practice Clinic" one of his colleagues who knew him for over a decade told the radiologist quietly, after he had gone.