"Samurai Radiologist" Exposes the Mysterious World of Imaging

Colin T. Son


February 03, 2009

Radiology is an interesting specialty. To begin with, it's young. It's also changing, as rapidly as any medical specialty. Maybe that's why, as the stereotype goes, radiology attracts an interesting group of physicians, including a number of "physician-geeks."

The Samurai Radiologist counts himself in that group. An academic radiologist with a crafty sense of humor, he began blogging at Not Totally Rad with the intent of commenting largely on radiology practice issues. And while he has done that, he has also shown a knack for shedding his radiologist's perspective and offering a broader view of medicine and life in general. He recently corresponded with me about medical technology and the future of radiology.

Colin Son: Radiology is a very tech-savvy medical specialty. Do you think that radiologists are more prone to being gadget and technology fiends?

Samurai Radiologist: We do get our share of geeks in radiology, and I'm a good example of that. My undergraduate degree is in physics and I did graduate work in biostatistics after med school. I also have years of electronics, ham radio, geocaching, and computer programming in my checkered past. I love making and using gadgets. I also love programming a tasty Web application when time permits. These things probably make me a bit of an outlier, even in a geeky specialty such as radiology -- an alpha geek, if you will.

However, there are quite a few radiologists who are very definitely non-geeks. I still have a number of colleagues who entered the computer age kicking and screaming, and then only because we stopped using film in our department.

Samurai Radiologist hosts Grand Rounds
February 3, 2009

Colin Son: What are some of the most profound changes that you've seen in your 20 years in practice?

Samurai Radiologist: Radiologists are pretty much the poster children for applied medical informatics. Other than a few patient procedures, I do just about all of my work these days via a workstation. Two big changes that I've seen since residency are direct digital imaging and widespread use of picture archiving and communication systems (PACS).

We've produced digital images with CT [computed tomography] since the 1970s, long before anyone had a digital camera. Since then, we've updated ultrasound, nuclear medicine, MR [magnetic resonance], and finally plain radiographs to all-digital capture. It's hard to overstate the importance of this. There are a lot of advantages:

  1. Image quality is way up. It's much easier to get evenly exposed shots of complex areas with digital.

  2. The retake rate is way down; if an image is under- or overexposed a bit, we can often adjust it on the computer rather than re-expose the patient to radiation.

  3. Digital copies are just as good as the originals and can be sent along with the patient to any other place where they want to get their care.

  4. No more hotlights! In the days of yore, there were so many overexposed films that every reading station had a special bright light to illuminate the really dark films.

  5. Reading images across the network is a great boon. An on-call radiologist can now roll out of bed, log in to a workstation on the bedside table, read an emergent study, and then be back in bed in 5 minutes. This sure beats driving to the hospital at 3 am.

Having a central hospital image archive has made life a lot easier for all caregivers. A good PACS system lets everyone in the hospital look at the same image at the same time. When all images were film-based, life in image city was a chronic "tragedy of the commons." Any time you wanted to see the images on a patient, it was all too likely that someone else had already checked them out. A big source of intern and resident scut work in those days was the need to hunt down critical images in the nooks and crannies of the hospital. It was quite common for one service to hide the films from other services until they had finished their part of the job. The abolishment of film hoarding has been a Great Good Thing for everyone.

Radiologists have a saying: "An old film is worth an extra year of residency." In the old days, bulging shelves of old films forced most departments to destroy images older than 5 years. Nowadays, a well-designed PACS archive should theoretically let one keep all of a patient's old films forever.

Colin Son: What do you think the future holds in terms of teleradiology and communication technology?

Samurai Radiologist: It has already had a huge effect. In the old days we had a whole legion of x-ray file room gnomes whose job was to load films onto giant film rotisseries called alternators, which were about the size of 3 or 4 soda machines duct-taped together. Radiologists would move from alternator to alternator all day long, with file room gnomes unloading and reloading the used alternators. The good side of this was the sense of accomplishment and closure you got from polishing off an alternator. Even if there were more films to read, you were forced to take a break until the gnomes could reload your alternator. Our workday consisted of 3 or 4 alternator sessions, each with definite beginnings and ends.

Our PACS system now divides up our daily workload by subspecialty and sends any unread images to a list on our workstations. This worklist grows as fast as our technologists can shoot new images. Therefore, there's always something on the list, no matter how fast we work. Our workdays now are often more like the old Lucille Ball skit about the conveyor belt in the chocolate factory.

Colin Son: Are there any negatives associated with rapid technological advances in radiology?

Samurai Radiologist: It's always harder to adapt to technology when it is rapidly changing. As usual, the most difficult things are not the technological hurdles but the social ones. Once we realized that we could read films remotely from home, there was really nothing stopping us from reading them from Hawaii or France or Asia. This has allowed all sorts of time-shifting, where wide-awake radiologists 12 time zones away read cases in places where most folks are asleep.

There are now large teleradiology practices that read images from all over the planet. Teleradiology has changed the radiology marketplace a great deal. Why have your images read by the local Joe Blow radiologist when you can have your images read by Well-Known Expert from Enormous Medical College? Likewise, why pay the going US rates for interpreting a knee MR image when you can get a great but less expensive reading from a well-trained, board-certified, US-trained radiologist in India?

This outsourcing phenomenon is a bit troubling to radiologists, who view giant out-of-state and offshore teleradiology groups much the way a local mom-and-pop store views Barnes & Noble or Wal-Mart. How does a local radiology store compete with this kind of competition? I don't have any good answers, other than to do my best to add enough value to my readings and consultations that my clinical pals will continue to shop locally. For what it's worth, I keep shopping at my local independent bookstore and computer store, even though Amazon's just a click away.

Colin Son: What have you seen in terms of how radiologists are using the Web?

Samurai Radiologist: Online teaching files are one of the most useful things I've seen. I've been putting teaching files on the Web since 1994 and am delighted to see how many other folks have since done the same. Around Boards time, our senior residents are pretty well glued to a monitor, obsessively reviewing every online case that they can get their hands on. We currently have almost 2000 cases in our online departmental teaching file, and I tap it constantly for case conferences, lectures, book chapters, and manuscripts.

Social networking seems to be big with our residents. In the old days, they would come to the faculty with questions about other programs, particularly when applying for fellowships. Nowadays, they seem to head for sites like Aunt Minnie instead. One of our newer faculty hires told me that news of his moving to our program was all over Aunt Minnie long before word leaked out in his previous department.

Online literature searches are another great thing. For most of my career, I was the only person in my department who could even do a literature search from their computer. Nowadays, our residents, fellows, and young attendings pretty much take PubMed and Google Scholar for granted.

Another enormous boon to our department has been the wonderful Web-based client that we have for viewing patient medical records. When I'm reading cases, I get the generic history of "pain" a lot more often than I'd like. Being able to immediately get more clinical information helps me immensely. I'm sure that my interpretations become more accurate and more clinically useful because of this. This same information system also lets me quickly tap the collective consciousness of other radiologists in my department by instantly bringing up their findings on old films of the same patient.

Colin Son: What can blogs offer to physicians?

Samurai Radiologist: I've spent my whole career writing scientific manuscripts, book chapters, and other academic fodder. However, scientific writing tends to be pretty darned formulaic -- it's rarely great literature. My blog is the first thing that I've ever written just for the fun of it. It has been a pleasant surprise to discover just how much more I enjoy writing when I'm not on deadline and the only editor I have to please is myself. I'm sure that my writing skills have improved considerably with all the practice I've gotten over the last year. Also, once I've processed my thoughts on some subject into bloggable form, I find that the concepts are much clearer in my brain for further use.

When I started blogging, I did have one initial concern: not having anything to say. I'm happy to say that this has been no problem at all. If anything, I've got more ideas than I have time to write about, with a current backlog of over 50 ideas.

When I post about ostensibly nonradiologic topics, I'm amused at how often I can find some facet relevant to my specialty. Hopefully, the things that I write about look a bit more intriguing when viewed through a radiologist's-eye view of the world. My post on how radiology gear has been used to study sexual intercourse turned out to be one of my most popular posts, as well as one of the most fun to write.

On February 3, 2009, the Samurai Radiologist hosts Grand Rounds, a weekly blog carnival featuring the best writing from medical blogs around the Internet.


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