Never offer to eat your pants -- plus 25 other golden rules

By Dr. Paul McCoubrie, AuntMinnieEurope.com columnist

February 20, 2013 -- In daily practice, it's worth remembering some simple rules of radiology -- the uber-truths that are the very essence of our dear specialty.

Rule 1: Respect the machines
Don't verbally abuse the scanner or let it know you are in a hurry. They have sensors for that and will shut down. They are particularly sensitive after 4:50 p.m., on Friday afternoons, on the birthdays of loved ones, and on anniversaries.

Dr. Paul McCoubrie
Dr. Paul McCoubrie is a consultant radiologist at Southmead Hospital in Bristol, U.K.

Rule 2: Forgive the sins of the clinician
They are just jealous. There are two types of doctors: radiologists and those who wish they were radiologists. After all, we have the most expensive toys and the comfiest chairs. Arguing with clinicians is like wrestling with a pig in mud ... after a while you realize the pig likes it.

Rule 3: Never let a clinician play radiologist
If the request gives specific radiological directions, you must do the opposite. A request for "CT with contrast" means they get an unenhanced scan; any request for "obliques" gets just an AP and lateral.

Rule 4: Aggressive clinicians need your help
If a doctor gets rude and starts shouting, they are usually (i) out of their depth, (ii) unsupported, and (iii) worried about their patient. See past the emotion and try to help. Persistent offenders need showing the door and reminding, "My scanner, not your scanner."

Rule 5: Work hard
It is the radiological trump card: "Yes, he may be a sociopath with body odor that makes paint peel but he works hard." But don't work too hard. You only have a finite time on this planet.

Rule 6: Toughen up
Modern medical practice is tough. Patients still die despite all best efforts. Other doctors aren't always nice to each other. No one said it would be easy. Develop a thick hide, become stoical, and just get on with it.

Rule 7: Be a good colleague
A good radiology department is where you show cases to each other on a daily basis. Experienced colleagues get their egos checked; younger colleagues get a helping hand. If you aren't doing this, you might be part of the problem.

Rule 8: Never measure anything
A radiologist with a ruler is a radiologist in trouble. If you can't measure it with the eyeball-ometer, you are out of your depth. Accurate measurements honestly don't matter. The nearest centimeter or so is absolutely fine.

Rule 9: Never count anything
If you are trying to equate quality or experience with activity, you are missing the point. You could be doing the wrong thing over and over again. Anyone who brays about their "numbers" is indeed an ass. If counting is the sole rationale, you are the wrong person to be doing it.

Rule 10: The default is to say "yes"
There are two sorts of radiology requests: requests from a competent and knowledgeable colleague, which you accept; and requests from an incompetent and bumbling colleague, which you accept right now. Saying "no" always involves more work in the long run.

Rule 11: Be damned careful when saying an outright "no"
The hardest part about being a radiologist is knowing when not to do something, when to say no. The clinician has seen the patient, you haven't. But if the most appropriate clinician hasn't seen the patient, feel free to say no.

Rule 12: There is no such thing as a radiological emergency
If the patient has a cardiac arrest in the department, it isn't strictly a radiological matter. Whilst it is polite to show an interest, they'd honestly be better off with the crash team. Otherwise, you should always finish your cuppa before the next task. Rushing things causes errors. Stay calm, stay safe.

Rule 13: If you feel resistance, stop pushing
This is the cardinal rule of interventional radiology. Same rule applies when cleaning one's external auditory meatus.

Rule 14: Use words carefully, brevity is king
Clarity of communication is everything. A good test is ruined by a poor report. Never, ever write, "Clinical correlation advised." The longer the report, the greater the uncertainty. Also, clinicians won't read it; anything longer than four lines and they skip to the conclusion.

Rule 15: Question everything
Dogma has no role in radiology. If you never doubt yourself, you are wrong a lot.

Rule 16: Ditch the stethoscope
Who are you trying to kid? You don't even know which one is "lub" and which one is "dub" anymore. Oh, and lose the bow tie. Seriously. It makes you look like a fool.

Rule 17: CT is easy
Real hardcore radiologists do loads and loads of plain radiographs. They do them quickly but take pride only in their accuracy. Anyone who "doesn't do plain films anymore" is a work-shy fop.

Rule 18: Don't answer the phone
It is not for you. The more you answer the phone, the more it rings. Even if it is for you, it isn't a social call. Ignoring it encourages face-to-face consultations. These are better for clinical care and certainly a lot more fun for the radiologist.

Rule 19: Stay safe the easy way
In a high-risk patient, the lowest rate of complications occurs when you don't meddle. Contrast nephropathy is unheard of if you don't give contrast. Patients don't exsanguinate from a biopsy that didn't happen.

Rule 20: Get off the fence
Do not let the fear of being wrong rob you of the joy of being right. If you absolutely have to equivocate, you are only allowed one hedge per sentence, "There appears to be a possible nodule" tells much, yet almost nothing.

Rule 21: Beware the 'good' case
The impressive case that you think you've nailed and thus triumphantly show to all and sundry is only a biopsy away from being a classic mistake.

Rule 22: Don't fret about complications
If you haven't encountered complications during a procedure, you haven't done enough of them. They will still happen irrespective of preparation, training, skill, carefulness, and clinical likelihood. The complications you worry about don't happen and the ones that do are unforeseeable.

Rule 23: We are not the business of exclusion
No test is 100% sensitive. We don't do "rule outs." Ever.

Rule 24: Don't crap on juniors
You can judge a doctor by how they treat those lower on the medical ladder. Those on the lower rungs need a hand up. A radiologist can provide help and education. Education, however, can be delivered pretty assertively. Especially at 3 a.m.

Rule 25: Know loads
The job of the radiologist is to explain every pixel. Not just hazard a guess, but to know categorically. If you can't explain something, you aren't as good as you thought you were.

Rule 26: Never offer to eat your pants
You might be so totally convinced in your diagnostic accuracy that you offer to do something silly if you are wrong. Sure as eggs are eggs, you will be tasting cloth sooner than you think.

For a longer version of Dr. McCoubrie's rules of radiology, click here. "Writing helps me make sense of the world," he said. "Moreover, I like to critically reflect on all things radiological. This blog is to pass on snippets of insight I have gained through these reflections."

Dr. Paul McCoubrie is a consultant radiologist at Southmead Hospital in Bristol, U.K.

The comments and observations expressed herein do not necessarily reflect the opinions of AuntMinnieEurope.com, nor should they be construed as an endorsement or admonishment of any particular vendor, analyst, industry consultant, or consulting group.


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