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A Typical Day With a Radiologist

Dr. Michael arrives in his office just before 8:00 a.m. and tries to set it up for the coming onslaught. He sets his stereo to soothing classical music and turns down the overhead lights. On this day, he is able to snatch five minutes of set-up time. But then the action starts. The phone rings—one of the receptionists is sending Dr. King down to the office. He wants to go over some films. Dr. Michael barely has time to look at today's schedule, which has him assigned to fluoroscopy-upper GIs and barium enemas, basically.

No sooner is he able to figure out his assignment, then one of the "fluoro" techs, Bernadette, comes into his office to cheerfully announce that the first UGI series is ready. Just then, Dr. King rolls in, so Michael tells Bernadette to hang on for a few minutes so that he can go over films with Dr. King. Fortunately, on this day, the findings on the films are found and explained quickly by Dr. Michael; while Dr. King explains the clinical circumstances and they compare notes.

Dr. King is very talkative today. His daughter just graduated from college and plans on going to graduate school and so on. Dr. Michael would love to chat with Dr. King about this, that, and another thing, but right now he has a patient and tech waiting for him in a fluoro room, so he must cut this social encounter short. These interactions with the clinical staff, a mixture of professional and nonprofessional, are a very important part of Dr. Michael's workday and important for the patient too. When a clinician and radiologist exchange medical information, the patient surely benefits. But Bernadette and the patient are still waiting.

It's just 8:15 when Dr. Michael walks into the fluoro room to do his first case. He introduces himself, induces the patient to drink barium, and takes a number of x-rays. This patient wants to know what is going on before she leaves. Dr. Michael is happy that patients are actually becoming enlightened consumers. He even shows the patient her esophagus on the fluoroscopy screen to which she exclaims "Gross!" That terminates the tutorial. Finished with the case, Michael goes back to his office to check if the emergency films have been read yet. In an acute care hospital, chest x-rays on certain inpatients are frequently obtained more than once a day. These patients are often very sick, and they are often awakened at first light for a daily chest x-ray; those films need to be read.

There is another rhythm in the hospital that is relentless—the emergency room, ER, emergency department, or whatever. So now in addition to a few ICU films, there are films that the ER doc who is now swamped wants read by a radiologist, and today that means Dr. Michael.

The person who is usually assigned these in-house ER cases is off at a medical staff meeting. The radiologists try to participate in hospital politics, but the meetings are often held at inconvenient times. Part of being a good radiologist is keeping yourself attuned to the needs of the hospital in which you are so conveniently ensconced. If you happen to be the only one around, you need to prioritize your work so that the most important things get done first and the things that can wait, wait. Sometimes when the group is shorthanded by illness or whatever, it may be necessary to keep filling in the breeches most of the day and then sort things out later. Today, one of Dr. Michael's partners is out sick, one is at a meeting, and the other is tied up with breast wire localizations and biopsies. Dr. Michael grumbles, but picks up the stack of emergency readings, gets a cup of coffee, and gets down to work.

The first of the lot is a chest x-ray on a patient who just had part of his lung removed. There is a tube in the chest cavity that is keeping the remaining part of the lung expanded, and the chest surgeon wants to know if it is staying expanded. Dr. Michael compares today's film with a series of recent films and comes to the conclusion that the chest tube is working properly, the lung is still expanded, and there is nothing else on the film that is new or worrisome. He dictates his report into a transcription pool and writes a very abbreviated report on the film jacket and on a slip that the clerk will read from very shortly.

In his report, Dr. Michael has tried to answer any questions asked by the referring clinician; has commented on the positions of the various support lines, catheters, and tubes; and has otherwise reviewed the film for all other abnormalities. If Dr. Michael doesn't specifically comment on a structure or a region, it would indicate that he has looked at it and finds it not worth commenting upon. In the old days when resources were not considered limited, doctor's reports were often very long and very redundant. Many radiologists who were trained and practiced in that era still do dictate elaborate reports that can run a full page or two of single-spaced type.

Just as Dr. Michael almost finishes the ICU batch, Dr. Bass from the emergency department right next door storms in demanding a reading on his films. Bernadette has the films from the first UGI series in her hands, and the patient wants to talk to him. "I'll be right there. Let me deal with Dr. Bass." Bernadette is put off yet again. But Dr. Bass is right, he needs Dr. Michael's attention. He has a patient in the ER with flank pain. He has gotten an abdominal x-ray that he wants read now. ER doctors, themselves, read films, but in that department radiologists are still the experts. So Dr. Bass, a fairly astute film reader himself, has decided to throw the film in Dr. Michael's face, which is something that Dr. Bass has a right to do. After a few pleasantries, the colleagues get down to the business of bringing together the clinical and radiological evidence and coming up with conclusions.

Now it's time for Michael to look at the GI films. So he sits down, arranges them on his view box, and looks them over carefully. To Bernadette, "Ok, nothing serious. Why don’t you have her get dressed, I'll talk to her in a few minutes." The cramped, tiny cubicle out of which Dr. Michael operates is really not the most hospitable of places, and he tries to avoid meeting with patients in there. Of course, if it is a very sensitive or confidential matter, it would be discussed in there with the door closed. But this was just the normal results of an upper GI series. Rather than bringing the patient in the office, he walks into the waiting room and invites her to a short "curbside" chat just a step away from the bustle of the department. For a variety of reasons, the patient has a fear of cancer and thinks that her symptoms suggested that she had it. She is greatly relieved to hear that there is nothing seriously wrong. Her day has been made. Dr. Michael's day is looking a bit brighter also.

In the afternoons, almost the entire medical community winds down. The internists who went on rounds in the hospital to see their patients go back to their offices to see outpatients in routine visits; the surgeons who wielded the knife in the morning go back to their offices to attend to office visits. Dr. Michael will have a variety of choices. He may sit in his office or at a workstation and review and report on his fluoroscopies he did in the morning, deal with emergency readings, or just read the stack of films waiting to be read, all the bone and spine films, the chest x-rays, and countless other studies that a busy community hospital department produces around the clock.

On some afternoons, his routine may be interrupted by an emergency study such as a carotid arteriogram. But on this day, Dr. Michael is assigned to the Women's Imaging Center where he will look at and interpret dozens of mammograms and a bunch of ultrasounds on GYN and obstetrical patients. Michael used to sit at a motorized view box that could hold 60 or so mammograms and read one after another. Almost all of these studies were done for routine screening and were normal. Now, and probably with very good reason, women are being told of their results right at the time of the examination. Dr. Michael likes seeing the relief in the eyes of the women with normal studies. Those with suspicious findings that need more views or ultrasound are resolved right on the spot. If there are serious findings, most radiologists would "lateral" this responsibility to the family physician who almost always has a closer relationship to the patient. So instead of sitting down with a slew of screening mammograms and reading them one after another, Dr. Michael will be interrupted frequently. This would, perhaps, diminish the effectiveness of screening just a bit but would significantly improve its humanity.

Many practices have a second radiologist look over the films, the so-called second reading. Dr. Michael has another ally, the computer. This "mammographic HAL" will review all the mammograms before Dr. Michael and place "X's" and "O's" at suspicious spots on the image. Dr. Michael smiles as he thinks of how his friend the computer works. It finds everything, which is mostly nothing. So the radiologist needs to review and reject 99.9% of all the big pickups marked out by the computer. But Dr. Michael is good-natured about the process and curses the computer only now and then. The machine has been shown to pick up significant things that a radiologist might miss. That does not happen very often, but even if it happens only rarely, isn't it worth it? The machines are costly and there are other controversial issues as well, including the value of a human second reading over a computer second reading, but now and then for the patient it might be a lifesaver.

Dr. Michael's afternoon passes in a quiet, civilized manner, completely unlike his morning. At 4:00 p.m. he returns to the hospital to check in on the main department. It's busy, so he grabs a stack of films and returns to his office to read them. His life is good, at least for today, because he is not oncall. Around 5:00 or 6:00, he'll be able to leave. He thinks with dread about his next turn on call, which is coming up tomorrow. Then his life will no longer be his. He will have to stay in the hospital until things are done, then be available for the rest of the night by beeper or phone. Under these circumstances, movies are impossible and even dinners out can be very tricky.

Late night calls used to be even worse. Now, though, Dr. Michael does not have to go in to the hospital to read studies. Instead, he has them faxed to his home computer which displays the images as clearly as at the hospital. Still, they come like a bolt of lightening in the middle of the night. The phone rings, he wakes with a start, picks up the phone, and tries to understand what is going on. Then he walks over to his computer and starts looking at the images coming down. Is anything very important going on where hours might make a difference? Generally, there is not, but that is not always the case. Dr. Michael appreciates the fact that the technologists cannot do their work from home and are forced to drive back and forth to the hospital. He tries to convey his sympathy but, more importantly, he tries to monitor the necessity of the late-night calls. If some can wait for the morning, which begins at 7:00 or even earlier, perhaps they should wait.

He calls the emergency room physician with his interpretation and then tries with mixed success to fall back to sleep. The last time Dr. Michael was oncall he had to read three CT scans and an ultrasound study after midnight. Worse yet, Dr. Michael was facing a whole weekend on call. Not only would he have to cover at night, but he'd have to work all Saturday and Sunday, mostly alone. Poor baby.

But for today, Dr. Michael is done. His department is fully covered by clerks, technologists, and other radiologists, and he is free do as he pleases until he starts all over again at 8:00 a.m. the next morning.

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