Editorial - Imaging in Medicine (2013) Volume 5, Issue 2
Why radiologists need to careRB Gunderman*, Amit S Rattan1
- Corresponding Author:
- RB Gunderman
Department of Radiology
Indiana University, 702 North Barnhill Drive
Room 1053, Indianapolis, IN 46202, USA
Tel: +1 317 948 6307
E-mail: [email protected]
caring ▪ economics ▪ ethics ▪ imaging ▪ radiology
“The secret of the care of the patient is in caring for the patient.”
– Francis Peabody (1858–1922)
In his 2012 book, ‘What Money Can’t Buy: the Moral Limits of Markets’, Michael Sandel argues that we are shifting from a market economy to a market society, in which the market is seen as the best way to understand every facet of human life . Everything we think, say and do can be viewed in monetary terms, assigned a price, and bought and sold. We have progressed so far down the path to becoming a market society that many radiologists might take it more or less for granted that the time and attention of a radiologist is a fungible – and expensive – commodity that should not be squandered.
This market view of radiology is reflected in many aspects of contemporary radiology practice. For example, the productivity of radiologists is measured in economic units (relative value units) that favor procedures over so-called ‘cognitive’ activities such as speaking with patients ; reading rooms are designed to minimize ‘interruptions’, such as face-to-face interactions with referring physicians ; and radiologists are kept at more than arm’s length from patients, whose concerns and questions might significantly compromise the efficiency with which they work.
Sandel describes such economic hegemony as a form of ‘corruption’, by which he means that some aspects of human life are distorted and debased by being treated as commodities. An obvious example would be children; how much would we take for our firstborn? The problem with such a question is that it asks an economic question about an inherently noneconomic reality, something whose worth cannot be expressed in dollars and cents.
If medicine is not really a profession, but just another way of exchanging money for service in a market economy, in which free and rational people should be willing to provide and purchase whatever they choose so long as they can agree on a price, then Sandel’s perspective offers little in the way of insight. But if, on the contrary, there are aspects of excellence in medicine that cannot be described, accounted for and prioritized in economic terms, then medicine, and by extension radiology, must continue to be regarded as a profession whose purpose is not merely economic.
We believe that medicine is an inherently professional – as opposed to merely economic – endeavor, and that all physicians, especially radiologists, must continue to serve as advocates for the importance of noneconomic purposes in their work. Patients are not merely healthcare payers, but suffering human beings who need to be able to trust that their doctor is doing what is best for them, even when it redounds to the economic detriment of the medical practice and hospital. Likewise, physicians are professionals, who put the needs of patients ahead of money making.
Consider the following example. An elderly gentleman with a history of prior therapy for prostate carcinoma presents for retroperitoneal lymph node biopsy. A radiology resident is tasked with interviewing the patient, explaining the procedure and obtaining the patient’s informed consent. From an economic point of view, informed consent is important, partly because failing to obtain it could subject the resident and attending physician to penalties such as loss of hospital privileges, and partly because it provides important protection from a lawsuit in the event of an adverse outcome .
There is another important economic consideration. A radiologist’s time is precious. Every minute a radiologist spends talking with a patient is a minute taken away from the revenue-generating activity – performing procedures and interpreting images. Therefore, ideally it is important for radiologists to keep such encounters as brief as possible. Of course, customer satisfaction is also a consideration, so the radiologist does need to avoid leaving the patient feeling completely ignored or unattended to. In general, however, less is more when it comes to radiologist productivity.
Fortunately, however, the resident in question did not approach the encounter with this mindset. Instead, he took his responsibilities as a medical professional seriously, putting the care of the patient ahead of economic self-interest and attempting to provide the patient the same sort of care he would hope a colleague would provide one of his loved ones. He introduced himself with a smile, explained the procedure and took the time to answer questions, establishing a real rapport with the patient and the family.
“Patients are not merely healthcare payers, but suffering human beings who need to be able to trust that their doctor is doing what is best for them...”
However, during the positioning, prepping and draping of the patient for the procedure, the patient was beginning to breathe audibly and develop tachycardia. During the interview, the patient had been rather stoic as he described his diagnosis and radical prostatectomy. However, now he was clearly becoming distressed. The resident paused, not because patient motion threatened the procedure, but because the patient needed sympathy and support. This gave the patient the opportunity to explain the reasons he was distressed; that his cancer “wasn’t supposed to come back” following his previously successful surgery.
Instead of focusing on the need for sedation, or the threat to the sterile field posed by the patient’s upset, the radiologist considered the situation from the perspective of his patient and the family in the waiting room; how they had entrusted their loved one to his care, and how he would feel if he found himself in the same position.
The resident made an important professional discovery. No amount of knowledge about anatomy and physiology, no quantity of expertise in image interpretation and no degree of skill in needle manipulation could help with this procedure. For the issue was no longer one of performing a procedure as safely, efficiently and in as technically proficient a manner as possible. Instead, it was one of caring for a human being. Physicians cannot always correctly diagnose a patient’s condition or provide definitive therapy; however, they can always comfort and care.
If a radiologist is merely a revenue-generating machine, then caring does not really matter, except insofar as it contributes to or detracts from money making. If a radiologist is first and foremost a physician and a human being, then caring not only makes a difference – in some crucial respects, it makes all the difference. What if a great radiologist is not merely someone who detects lesions that others miss, but someone who does a particularly good job of caring for patients, families and even colleagues, both inside and outside the radiology department?
Approximately half of the general public does not even know that radiologists are physicians, yet the majority of patients would like to know more about the physicians interpreting their images. Given the opportunity to interact directly, the vast majority of patients report that they were favorably impressed and appreciated the opportunity to meet their radiologist .
“In the radiology department, the radiologist is the patient’s physician.”
To enhance caring among radiologists, we need to look beyond the dictates of the marketplace and surveys of referring physician and patient satisfaction. Instead, we must look to our selection criteria for radiology residents. We need to ask ourselves whether we allow ourselves and our colleagues to get away with callous conduct. We need to think seriously about the radiologists we most admire, and do our best to select, retain, promote and recognize the very best human beings in our midst. Before we can be great radiologists, we must first become great human beings.
We need to see ourselves not just as technologists or technicians, interpreting images and performing image-guided procedures, but as physicians, who aspire to be worthy of the trust our colleagues and patients place with us, whether we ever meet them or not. Trust is not a technical matter, nor is it an economic matter. It is above all a human matter, grounded far less in an economic transaction than in a human relationship. What we need to see is not an insurance card or a quarterly financial statement but the face and eyes of another human being.
To a radiologist, the retroperitoneal lymph node biopsy might have been just another procedure, although one contaminated by inappropriate patient conduct and, therefore, a black mark on the radiologist’s productivity record. However, instead, the radiology resident treated the situation not as an unpleasant deviation from preferred standards of patient conduct, but as an opportunity to call upon and embody the essential excellences of a physician and human being; namely, the capacity to care. In the radiology department, the radiologist is the patient’s physician .
Financial & competing interests disclosure
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.
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- Miller P, Lightburn J, Gunderman RB, Miller D. Radiologists’ role: the patient’s perspective. Presented at: Radiological Society of North American 98th Scientific Assembly Annual Meeting. Chicago, IL, USA, 25–30 November 2012.
- Borgstede J. It’s about the patients. J. Am. Coll. Radiol. 2(7), 555–556 (2005).
- American College of Radiology. Radiologist productivity measurement. www.acr.org/Membership/Residents-and- Fellows/Resident-Resources/~/media/2DF7F F7E1D444175B4BAD8C79019C2CF.pdf
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