Rules of Radiology: A guide for the perplexed and open-minded

By Dr. Adrian Brady, contributing writer

March 25, 2021 -- Hammurabi, Moses, and Napoleon are among the great historical lawmakers. In medicine, notable rules to guide and govern our practices have been promulgated by authorities as diverse as William Osler and Samuel Shem. Now, to this pantheon of luminaries, we can add Dr. Paul McCoubrie.

Depending on where we live (and how well-behaved we are), life is a combination of abiding by rules and exercising our individuality, different aspects of life being governed to different extents by these opposing influences.

Few jobs can be best performed by giving supremacy to individualism (the arts, perhaps, and oppositional politics); the practice of medicine certainly requires adherence to norms of performance. And yet, those norms are often understood and implied, rather than explicitly stated. The socially unconscious, the inept, and the deliberately anarchic may ignore them or never appreciate them.

To help those of us who fall among those categories, McCoubrie -- a consultant radiologist in Bristol, U.K., and regular columnist on -- has recently published the first volume (a second volume is in the pipeline) of his Rules of Radiology, in which he educates, guides, and amuses his readers while telling us the essential stuff that's often said in private conversation among ourselves but rarely committed to print.

Lighthearted, humorous cartoons are an essential feature of Rules of Radiology
Lighthearted, humorous cartoons are an essential aspect of the book. “By way of introduction, I'm a middle-aged, male, white radiologist,” writes McCoubrie. “I’ve specifically tried to avoid any cultural bias but if some unconscious bias has crept in, I apologise. This said, The Rules apply to all radiologists irrespective of age, gender, cultural heritage or country of residence.” Illustrations by John Charlesworth. All figures courtesy of Dr. Paul McCoubrie and Springer.

McCoubrie ranges widely, from general exhortation to do our jobs well (Rule 29, Get off the fence), to wisdom born of years of experience (Rule 40, Never offer to eat your pants). He describes the book as "a letter to my younger self"; it's intended to instruct those in the earlier years of their practice in aspects of their professional lives that are vital to being successful and useful as radiologists but which they won't find written down in any textbook. It can be considered as a passing on of wisdom from one who has thought deeply about who we are and what we do, and who knows how to impart what he's learned while making the reader laugh out loud (Rule 2, Smile).

A potted plant type of radiologist would be ideal from a work output point of view
A "potted plant" type of radiologist would be ideal from a work output point of view. Show it a radiograph and the lack of reaction can be taken as the plant thinking this is normal. “You can show the plant many hundreds of studies an hour and the reaction will be the same. And given that over 95% of radiological studies are normal or near normal, its error rate will be less than 5%. And who wouldn’t settle for an accuracy rate of more 95%? I’ve met a few potted plants in my time,” McCoubrie writes.

The author's own characteristics are freely on show: kindness (Rule 8, Forgive the sins of the clinician; Rule 38, Aggressive clinicians need your help), firmness (Rule 7, Never let a clinician play radiologist; Rule 43, Only give clinicians 15 seconds; Rule 21, There is no such thing as a radiological emergency), and sartorial elegance (Rule 41, Radiologists don't wear suede shoes).

Why we need rules

Can radiology practice be enhanced by considering and abiding by rules? Certainly! Those among us who believe they cannot be better than they are have either given up, lost their perspective, or missed their calling to national politics.

Climbing the medical ladder requires a thick hide
Climbing the medical ladder requires a thick hide to withstand the metaphorical attacks that inevitably occur during postgraduate training. “On the flip side, I don’t know many radiologists who are emotionally dead, impervious to the opinions of others, bereft of normal social graces. Underneath a radiologist’s mental armour usually beats the heart of a normal human,” the author writes.

Reflecting on how we do our work, being open to advice, direction, constructive criticism (and praise, when it's due) cannot but help us to be the best radiologists we can be. Closing our minds to the possibility of change or improvement in our work practices ensures we'll never achieve our full professional potential. Believing we're already perfect will ensure professional failure -- and the disdain of our wiser colleagues. Most of us will never achieve perfection (St. Augustine, "Lord, make me chaste, but not yet."), but we can hope and try to get a little closer to it all the time.

I've heard many brief, pithy summaries of things to do (or aspire to doing) and things to not do in radiology over the years. "Be available, be involved, be useful, be accurate, be amenable, be visible." "Don't be remote, don't be equivocal (or at least unnecessarily so), don't be afraid of committing yourself."

Is it OK to reassure a nervous patient? A compassionate radiologist might squeeze their hand, look them in the eye, and reassure them, but you could argue this is unethical as reassurances are a form of coercion
Is it OK to reassure a nervous patient? “A compassionate radiologist might squeeze their hand, look them in the eye and reassure them that they are in the best hands. But you could argue this is unethical as reassurances are a form of coercion. You might not be intending to but it is an easy trap to fall into.”

McCoubrie's book goes beyond these laudable aphorisms. It looks at many complex aspects of radiology practice, analyzes the reasons why these can be troubling or successful, and it advises on how we should approach them.

Dr. Adrian Brady
Dr. Adrian Brady.

Many years ago, when I worked on another continent, a colleague suggested that a copy of the radiology billing codes should be kept in the smallest room of the house, for ease of consultation when a few spare minutes presented themselves. This book is much more appropriate reading in that location -- and much more fun. It'll make you laugh, it'll make you think, it'll make you a better radiologist. Buy it, read it, then buy 10 more copies for your trainees. They'll benefit from it, and McCoubrie needs the money. He has children to raise.

Dr. Adrian Brady is a consultant radiologist at Mercy University Hospital, Cork, Ireland, and first vice-president of the European Society of Radiology.

Copyright © 2021

To read this and get access to all of the exclusive content on create a free account or sign-in now.

Member Sign In:
MemberID or Email Address:  
Do you have a password?
No, I want a free membership.
Yes, I have a password:  
Forgot your password?
Sign in using your social networking account:
Sign in using your social networking