Patients-not just Images
Devoted to Education and Practice in Patient-centered Radiology
RR's Aphorisms
RR's Aphorisms
Ravi Ramakantan
Ravi Ramakantan
1. A good history is worth a thousand images!
1. A good history is worth a thousand images!
In the words of the legendary Sir William Osler "Listen to the patient - he is telling you the diagnosis" .
In the words of the legendary Sir William Osler "Listen to the patient - he is telling you the diagnosis" .
CT scans, MRIs and PET scans do not change this basic rule of patient care!
CT scans, MRIs and PET scans do not change this basic rule of patient care!
2. There is no rule in radiology that you cannot talk to or examine a patient. After all, you have an MBBS degree!
2. There is no rule in radiology that you cannot talk to or examine a patient. After all, you have an MBBS degree!
3. There are no "interesting cases" - only unfortunate patients
3. There are no "interesting cases" - only unfortunate patients
4. Before you perform/report an imaging study, you should endeavour to know:
4. Before you perform/report an imaging study, you should endeavour to know:
> Why has that study been asked for – often we call it “indication”
> Why has that study been asked for – often we call it “indication”
> You should know what is being specifically looked for that will help further medical or especially surgical treatment. Reports that do not take the above into consideration and do not answer the above questions – I call them ‘assembly line” reports are not worth the paper that they are written on!
> You should know what is being specifically looked for that will help further medical or especially surgical treatment. Reports that do not take the above into consideration and do not answer the above questions – I call them ‘assembly line” reports are not worth the paper that they are written on!
5. When in doubt about the above try your best to find out from the referring physician about these. Remember at all times that “the only stupid question is the one that was never asked”.
5. When in doubt about the above try your best to find out from the referring physician about these. Remember at all times that “the only stupid question is the one that was never asked”.
6. In all relevant situations, pick up the phone and communicate findings to the referring physician. Remember that just like patients, referring physicians do not come in the way of your work, they are your work!
6. In all relevant situations, pick up the phone and communicate findings to the referring physician. Remember that just like patients, referring physicians do not come in the way of your work, they are your work!
7. In any imaging study, 'ignore' the obvious ! The obvious - even a ward boy - can diagnose. Keep looking for more findings – remember there is no substitute to spending time on images. Elsewhere in this website, I have elaborated on this as the
7. In any imaging study, 'ignore' the obvious ! The obvious - even a ward boy - can diagnose. Keep looking for more findings – remember there is no substitute to spending time on images. Elsewhere in this website, I have elaborated on this as the
8. At all times too, remember Ben Felson’s WGC – the ‘World’s Greatest Consultant' to a radiologist – is the patients’ previous imaging studies; it is equivalent to the ‘past history' that a physician tells you about. Ever so often, these studies will solve the problem for you.. keep plugging away at the patient till he and you are sure that there INDEED are NO previous images of any kind. By the way, I smile to myself, when I hear the phrase "past history".. .. all history is past!! Patients have a way of 'hiding' their old images in the 'plastic bags' they get along. I always ask "What do you have in that plastic bag?"
8. At all times too, remember Ben Felson’s WGC – the ‘World’s Greatest Consultant' to a radiologist – is the patients’ previous imaging studies; it is equivalent to the ‘past history' that a physician tells you about. Ever so often, these studies will solve the problem for you.. keep plugging away at the patient till he and you are sure that there INDEED are NO previous images of any kind. By the way, I smile to myself, when I hear the phrase "past history".. .. all history is past!! Patients have a way of 'hiding' their old images in the 'plastic bags' they get along. I always ask "What do you have in that plastic bag?"
9. One verified diagnosis is more learning than a million unverified ones.
9. One verified diagnosis is more learning than a million unverified ones.
It is not just about being right 90% of the time; it is more about knowing of the 10% of the times when you were wrong. The only way is to follow up on your patients. Start doing this on your very first day of residency and it will become a lifelong habit. There is NO BETTER WAY to learn.
It is not just about being right 90% of the time; it is more about knowing of the 10% of the times when you were wrong. The only way is to follow up on your patients. Start doing this on your very first day of residency and it will become a lifelong habit. There is NO BETTER WAY to learn.
10. Patients are in pain, fear and anxious about the results of their imaging studies. If you were one of them, you will realise how early you would want to know the results. So be prompt in reporting the study - not simply because the Turn Around Times in your department demand this but especially because you care!
10. Patients are in pain, fear and anxious about the results of their imaging studies. If you were one of them, you will realise how early you would want to know the results. So be prompt in reporting the study - not simply because the Turn Around Times in your department demand this but especially because you care!
11. Here is the Google definition of the word Clinician “a doctor having direct contact with patients rather than being involved with theoretical or laboratory studies.”. Decide for yourself if you want to be one.
11. Here is the Google definition of the word Clinician “a doctor having direct contact with patients rather than being involved with theoretical or laboratory studies.”. Decide for yourself if you want to be one.
12. Never hesitate to learn from your referring physicians; there is no shame in saying “I do not know”. After all, what we practice is about our patients and not about us!
12. Never hesitate to learn from your referring physicians; there is no shame in saying “I do not know”. After all, what we practice is about our patients and not about us!
13. And, at the end of the day, as you hit the bed, ask yourself “what did I do today that made a material difference to patient management”.. be honest and seek an honest answer. I need not elaborate further.
13. And, at the end of the day, as you hit the bed, ask yourself “what did I do today that made a material difference to patient management”.. be honest and seek an honest answer. I need not elaborate further.
14. Off and on, It is good to have a healthy skeptical attitude to what you may hear from your seniors and teachers. And, if you find your teachers were in error, it is essential to let them know - if necessary - . in an non offensive and disarming way.
14. Off and on, It is good to have a healthy skeptical attitude to what you may hear from your seniors and teachers. And, if you find your teachers were in error, it is essential to let them know - if necessary - . in an non offensive and disarming way.
See the William Osler page on this website.. get "enlightened"!
See the William Osler page on this website.. get "enlightened"!
15. Read widely on diverse subjects - beyond Radiology and Medicine; this freshens the mind and opens up room for new thoughts and attitudes.
15. Read widely on diverse subjects - beyond Radiology and Medicine; this freshens the mind and opens up room for new thoughts and attitudes.
16. You SHOULD cultivate an "indoor" hobby and an ourdoor game as a part of your being. These are the ones that will sail you through difficult times; Besides you will feel refreshed to meet with non medical folks when you practice these activities. this is important to be a doctor.
16. You SHOULD cultivate an "indoor" hobby and an ourdoor game as a part of your being. These are the ones that will sail you through difficult times; Besides you will feel refreshed to meet with non medical folks when you practice these activities. this is important to be a doctor.
17. Do not let a failure in an exam get you down. There will always be a Second Attempt !
17. Do not let a failure in an exam get you down. There will always be a Second Attempt !
18. When was the last time you asked "WHY" for something that you saw in radiology?
18. When was the last time you asked "WHY" for something that you saw in radiology?
Once in medicine, seldom, are you trained to ask "Why". Make it a habit.. "why this.. why that.." After all , if Issac Newton had not asked "why"...
Once in medicine, seldom, are you trained to ask "Why". Make it a habit.. "why this.. why that.." After all , if Issac Newton had not asked "why"...
Here are some examples :
Here are some examples :
For long, I have wondered, WHY is it that the olecrenon is invariably involved in mutifocal pediatric skeletal TB? .. or that 'sclerotic' tuberculous osteomyelitis i so common in the metatarsals - especially the first. There is a pattern here. These patients invariably are in their teens and often from "well to do" families.
For long, I have wondered, WHY is it that the olecrenon is invariably involved in mutifocal pediatric skeletal TB? .. or that 'sclerotic' tuberculous osteomyelitis i so common in the metatarsals - especially the first. There is a pattern here. These patients invariably are in their teens and often from "well to do" families.
WHY is it that the peanut is the most common foreign body in the bronchus? or
WHY is it that the peanut is the most common foreign body in the bronchus? or
WHY do patients with torsion of the testis generally come to the emergency room between 2 AM and 4 AM?
WHY do patients with torsion of the testis generally come to the emergency room between 2 AM and 4 AM?
WHY do the pulmonary and hepatic veins have a venous confluence similar to that of the veins in a leaf- why not just a dichotomous pattern - like other veins in the body?
WHY do the pulmonary and hepatic veins have a venous confluence similar to that of the veins in a leaf- why not just a dichotomous pattern - like other veins in the body?
I am still looking for answers. If you know or do find out, please let me know.
I am still looking for answers. If you know or do find out, please let me know.
One time, for want of anything better to do, I wondered, "How did air get into the coconut?". Think up an answer yourself and then read this page!
One time, for want of anything better to do, I wondered, "How did air get into the coconut?". Think up an answer yourself and then read this page!
19. And finally, as I said before, always remember that patients do NOT come in the way of your work; they ARE your work. Talk to them, answer their questions in keeping with the traditions and ethics of being a radiologist - reassure them and address their anxieties before and after a radiologic examination. This is what being a radiologist means to me.
19. And finally, as I said before, always remember that patients do NOT come in the way of your work; they ARE your work. Talk to them, answer their questions in keeping with the traditions and ethics of being a radiologist - reassure them and address their anxieties before and after a radiologic examination. This is what being a radiologist means to me.
* An aphorism is a concise, terse, or memorable expression of a general truth or principle In calling the above as my 'Aphorisms" I am not trying to be proud or pompous. This is what I have learnt from my 40 odd years of the practice of Radiology.