When I was interviewed for my training post in radiology I was asked why I wanted to enter the specialty. I realised that the honest answer would not get me the job: “Surgery and I have come to the mutual realisation that I will never be a surgeon, and I can’t get a job in anaesthetics. The X-Ray department is the place in my present hospital where folk go to socialise over a cup of coffee. Everybody seems nice, so I thought I would give radiology a go”. Instead I gave the answer that I had prepared earlier: “Radiology is at the cutting edge of clinical medicine with exciting new diagnostic technologies being introduced and radiologists are pushing back the frontiers of minimally invasive treatment”.
When I started my radiology job the following week (yes, I was getting kind of desperate) the reality was somewhat different. Yes, there were some radiologists pushing back the frontiers, experimenting with new technology, but the reality of everyday radiology was somewhat different in 1980.
This was arguably the tail end of the golden age of diagnostic clinical medicine as an art form. As recent medical students we had been taught by some of the clinical gods of Glaswegian medicine that the key to diagnosis was a detailed clinical history and a meticulous clinical examination. Obviously, as a surgical resident you had to learn how to clerk-in 8 patients in an hour for routine elective surgery but, if you were a medical junior, then woe betide you on the ward round if you had not spent an hour or so on each patient taking note of every detail of their clinical and social history, and performing a meticulous clinical examination of every body system. That process would be gone through by the resident, the SHO, the registrar and/or the senior registrar. The findings would be presented to the consultant on the ward round, who would elicit further gems from the history, and clinical signs that had previously been missed. Some consultants would do that in a spirit of education; some would use those gems as weapons of humiliation against those who had missed them. A diagnosis would be made, perhaps with one or two alternative suggestions. The job of radiology was then, with the limited tests available, to confirm that diagnosis.
We had a limited arsenal of tests. Plain x-ray films were pretty good at what they did by present standards. Nuclear medicine scans wouldn’t be totally out of place today. There were various x-ray dyes and suspensions to outline specific body parts on x-rays, almost none of which are used today. Ultrasound machines and CT head scanners were almost unbelievably crude by today’s standards.
However, technology was rolled out in radiology and the diagnostic capabilities of the equipment increased significantly with the advent of whole-body CT scanners and MR scanners. In Dumfries at times we were near that cutting edge of technology, with the first full field digital mammography unit and the first multi-detector CT scanner in the country.
However, with the advance in technology, we have lost the variety of radiological techniques that we used to have. When I started in Dumfries as a consultant radiologist in 1986, in the first month I carried out 13 different kinds of radiological test, all of which required my practical input, and only one of which, ultrasound scanning, we still use. Now over 80% of a radiologist’s time is spent sitting at a computer screen looking at digital x-rays, CT and MR scans.
On a visit to Norway in 1999, I met a radiologist who offered to show me round her department. It had recently become fully digital with no x-ray film any more. All studies were reported on digital work-stations. It was way ahead of anything in this country and looked very impressive. I said it must make a tremendous difference to the way you work. Yes, she said, we are now computer operators sitting here all day and I can’t do this for another 20 years, so I am resigning and going to be a farmer.
I understand what she was saying. It is easy to feel like a hamster on a wheel, spinning ever faster but never keeping pace with the increase in demand for radiology. There are many reasons for that increase, currently around 5% per year, not least of which are the guidelines Angus talked about in last week’s blog.
There are upsides. There is an intellectual variety which we never had before, due to the wide range of pathologies we can image. You are sitting at a computer, so if you come across something you don’t know, you can go on a Google expedition to fill that knowledge gap. We still have a long way to go though before radiology (and lab tests) can give all the answers, so there is still a place for those old-fashioned clinical skills.
Dr David Hill (@davidmhill55) is a Consultant Radiologist at Dumfries and Galloway Royal Infirmary
Next weeks blog will be by Susan Roberts, Clinical Pharamcist