Posts Tagged ‘Radiology’

“Stop worrying - radiation is good for you!”

By Bob Bury - 1st December 2010 7:17 pm

There are some scary people out there. A couple of weeks ago, I gave a public lecture at the Royal Society of Medicine on behalf of the Royal College of Radiologists. It was about the changing public attitudes to radiation since its discovery, and more particularly about maintaining a sense of perspective concerning the risks of the radiation used in diagnostic imaging. I called it ‘Stop worrying - radiation is good for you’, because if you’re doing a lecture for the public you need a title which will grab their attention. In the unlikely and slightly worrying event that any of you have nothing better to do for 46 minutes, you can find the video here.

The burden of my message was that the radiation we use in imaging is good for you because we go to considerable lengths to ensure that exposures only occur when the potential benefits outweigh the (very small) risk. As a titillating footnote, though, I mentioned radiation hormesis - the theory that small doses of ionising radiation really are good for you, and actually reduce the risk of cancer. There is quite good scientific evidence for this, but as I pointed out, that doesn’t mean that we can relax and just irradiate everyone willy nilly - it would soon be possible to exceed the doses that even the keenest proponents of hormesis think might be good for us if we allowed the unbridled use of CT scanning, with no regard for radiation protection.

The talk attracted some media interest, which was one of the reasons for doing it, and I had a long telephone interview with Jeremy Laurance, the health correspondent of The Independent. Although he’s one of the more responsible health journalists, his first concern has to be engaging the interest of readers, so when his article appeared last week, it was no surprise that my ‘footnote’ had become his main feature, with my message of reassurance relegated to a line or two towards the end. But at least he had reported me accurately, and it could have been a lot worse. Today, though, I had a look at the online comments relating to the article.

Although we all know there are a lot of single-issue nutters around, it is always a bit disturbing to see them in full flow. Take, for example, the contributor who raged that ‘everyone is dying’ as a result of radiation in ‘hospitals and airport scanners’. I couldn’t be bothered going through the registration process in order to post a reply, and it would clearly have been a waste of time in any case. Luckily, a number of other contributors said everything that needed saying.

Of course, the ironic thing is that the sort of people (sweeping generalisation alert) who get the risks of radiation so out of proportion are almost certainly cyclists. In fact, they probably knit their own cycle helmets out of tofu. And of course, far more people die every year from that highly hazardous activity (cycling, not knitting) than are damaged by the negligible radiation doses from the nuclear industry or airport scanners.

Still, it was reassuring in a way. It confirmed that we weren’t wasting our time by attempting to increase public awareness in this controversial area.

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Forget A&E, put radiology at the front door

By Bob Bury - 3rd May 2010 11:26 am

So we need double the number of A&E consultants? I don’t think so.

The reason A&E is knee-deep in whinging patients is because most of them don’t have anything wrong with them. They’re only there because they rang NHS Dire, and some nurse or spotty work-experience yoof reading from the wrong list decided that the caller’s unfocused sense of unease and general dissatisfaction with the twenty-first century might actually be an indication of acute meningococcal septicaemia.

What we need in A&E are more scary, middle-aged proper nurses to tell them to f-off and stop bothering doctor. And then, once you’ve kicked out the inadequates and malingerers and sent them back to the GP (or to be more exact, the practice nurse, now it’s impossible to actually get an appointment with the GP), you can employ more proper doctors in A&E. And what I mean by ‘proper doctors’ is radiologists.

Clinicians spend their lives moaning about poor access to imaging facilities, and this will matter even more now that medical students spend all their time in empathy workshops instead of learning anatomy, and qualify with the clinical skills of a golden retriever. None of them will have a clue what’s wrong with their patient until we have worked our radiological magic, so here’s what we need to do.

Having wittered on for most of my career about how radiology needs to be at the centre of the hospital, I have changed my mind. It needs to be at the front door, staffed by radiologists who are now the only generalists in an age of super-specialisation, and equipped with the finest that Siemens, GE et al have to offer. Clincians would only be allowed to see a patient once we have decided that he might actually benefit from the skills of a specialist in non-infective interstitial diseases of the left lung.

This would save enormous amounts of money. No need to equip sections of damp corridor with rusty trolleys and put up signs saying ‘Clinical Decisions Unit’ in order to circumvent the four-hour A&E target. The clinical decisions will all be made by people sufficiently good-looking, clinically gifted and technologically equipped to undertake that role. No more patients hanging around in beds waiting for scans or results of scans, and no more hapless SHOs (or whatever they’re called now) sent into the dragon’s den to ask radiologists to perform unnecessary investigations requested by their bosses for reasons which escape everyone.

There - job done. We’ve saved all the money we need to pay the bankers’ bonuses and clear the national deficit, and saved countless lives in the process.

Oh, wait a minute. Have just realised that this will only work if we use ‘proper’ radiologists (yes, of course like me). I had forgotten that the ABCFY1s or whatever will be coming directly into radiology after 20 minutes experience on a dermatology ward in the West Midlands, and won’t actually be any more clinically savvy than any of the other clincians.

Bugger.

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Expose the dangers in radiological outsourcing

By Dr Tom Goodfellow, member of the HCSA executive - 22nd September 2009 9:28 am

The advent of digital technology allows radiological images to be sent to any part of the world and the ‘Scans-R-Us’ mentality is now stimulating a strong marketing drive among teleradiology companies.

Indeed there is now a cut price war going on with the work being awarded to those who come in cheapest.

Although all the various companies claim governance, the reality is that the world-wide market is almost completely unregulated in any meaningful way. There have been some EC initiatives to address the problem. However spread across 27 healthcare systems and involving three European Directorates it seems highly unlikely that this will produce any results for many years.

There is no doubt that teleradiology has a role in supporting the delivery of diagnostic imaging. However the outsourcing of imaging has a very chequered history in the UK, let alone the rest of the world. For example the initial first wave of MRI outsourcing caused such clinical concerns that the Department of Health were forced to involve a senior member of the Royal College of Radiologists as clinical guardian to put in place proper governance and quality standards.

The practical, ethical and medico-legal issues of international outsourcing are immensely complicated. However, the heart of the matter is the inherent injustice whereby UK-based radiologists will be required to undergo a stringent revalidation process every five years in order for them to be allowed to practice and to ensure patient safety, while NHS trusts may utilise the (cheaper) services of international radiologists through teleradiology who do not have the same requirements placed upon them. Indeed most countries do not even have the equivalent of the FRCR examination.

In December 2008, two representatives of the HCSA visited the GMC in London to discuss this issue. However although receiving a sympathetic hearing the overall message was that, despite recognising the concerns, the GMC were only able to regulate doctors registered in the UK.

At their suggestion the issue was brought to the attention of the Care Quality Commission. In response Mr. J. Rentoul, CQC director of regulation & strategy, copied the HCSA into a letter which has been sent to the GMC this summer.

This states: “The Care Quality Commission believes that it is in the best interests of UK based patients that all doctors who are delivering telemedicine services to them are regulated to UK standards. Those who are commissioning telemedicine services from doctors based outside the UK are advised to ensure that doctors are appropriately qualified and regulated. They should demonstrate via their regulatory body or through other means that they are up to date and fit to practise.

“The CQC expects those who commission such services from outside the UK to ensure that those providing them are appropriately qualified and regulated, and that there are established arrangements in place for quality assurance”.

Although this statement still leaves unanswered questions it is clearly a much better position than before.

Trusts seeking to outsource radiology will be required to do more than pay lip service to the quality and regulatory issues involved. Any doctor who believes that this is being flouted in the interests of cost-saving should, after seeking local resolution, take the matter straight to the CQC for support. 

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Quality compromised in pursuit of cheap volume

By Dr Tom Goodfellow, consultant radiologist - 27th July 2009 1:15 pm

Now I am not one to moan and I know that the most dangerous place in a hospital is reputed to be the door to the X-ray department at 5.00pm (you may get run over by the rush of radiologists leaving)!

But I had noticed that my work load seemed to be steadily rising despite my best attempts to prevent it.

So we decided to review the radiology work load figures for the last three years and the increases were quite unbelievable. CT had increased by 61%, ultrasound by 71% and MRI by a staggering 101% (and I am talking thousands of scans, not hundreds). This huge rise in demand for imaging investigations is reflected nationally, but I suspect we are at the extreme end of the curve.

The reasons for this surge are fairly straightforward. Firstly, we have abolished significant waits for investigations, an achievement for which we are justifiably proud. But this has effectively taken the lid off Pandora’s box - long waiting times were an efficient means of controlling demand.

Secondly, the combined effect of MMC and the WTD has resulted in junior doctors with far less experience and confidence than in former times. Consequently they have a much lower threshold for requesting imaging investigations. This is not a criticism, merely a statement of fact.

Thirdly, public expectations of what the health service can deliver continue to be inflated by politicians. I am reminded of a headline in the Daily Garbage some time ago: “Death rates continue to fall”!

It is true that a significant number of these requests are utterly inappropriate. Earlier today I scanned the kidneys of a frail confused elderly lady with deteriorating renal function. My report stated: “Bilateral 91-year-old kidneys”. We then shipped her off to have a CT scan of her brain (same age). I am not ageist and believe that appropriate investigations should be done at any age, but it’s difficult to know how the results would have altered her management.

You would expect that the response of the trust management would be to rapidly recruit additional general radiologists to deal with the increasing work load. Did they heck! We calculated the shortfall as between eight and 12 WTE consultants. Eight months after we raised our concerns they offered us four, then immediately reduced to three.

It is not as if we are not earning the cash. Last year, based on tariff, we brought in about £20m of business. However our actual annual budget is about £7.5m and we are expected to make a 5% cost improvement this year. We must be the most cost-efficient department in the whole hospital. Yet where has the cash gone? To support the most inefficient parts of the service who still fail to hit the targets despite having millions thrown at them (I mention no names).

So a pretty depressing story. We have managed the work load by ditching the easy things like IP reporting (perversely usually the sickest patients) and by generally reducing the quality of the work we do. Sadly this has resulted in clinical errors, some serious. The clinical governance issues do not need to be spelled out.

Our trust is travelling down the road towards foundation status, yet sadly it seems that nothing has been learned from the Mid Staffs debacle.

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