Inch-wide mile-deep radiology
The weary joke about sub-specialisation in medicine goes that a team providing cutting edge care for big toe pathology fears obsolescence in the face of increasing big toe technical and academic advancement and eventually splits. Team hallux sinister and team hallux dexter are born. Like all worn-out jokes, there is an underlying kernel of truth.…
Excellence, or is good-enough radiology good-enough?
Some questions: The RCR Quality Standard for Imaging provides a starting point in setting out a comprehensive quality baseline for a radiology department with detailed descriptors across many domains. It describes a service fulfilling the imaging need of the population it serves quickly, safely, effectively, collaboratively and with dignity. A excellent imaging service should (arguably)…
Getting the basics right
It’s Thursday morning in late 1999, a grey gloomy day in London, the clouds heavy with the threat of another grimy shower. The celebrations of the forthcoming millennium seem a long way off, tainted by the fact that I will be on-call for it, and by an ongoing row stoked by the right wing press…
NHS workforce and the reality distortion field.
The process of designing the first Apple Macintosh computer in the early 1980s was an arduous one. The exacting demands of Apple co-founder Steve Jobs resulted in his employees and colleagues describing a ‘reality distortion field’ around him and the people who came into his orbit, within which the impossible became possible. Rectangles with rounded…
Parachutes, belief and intellectual curiosity
“There is no evidence that jumping out of a plane with a parachute improves outcome” “If you go to PubMed, you will find no publications that breathing air is good for you” “There’ll never be a trial, we are beyond that” Have you ever heard these statements made when someone discusses the evidence about a…
Values, guidance, NICE and the ESVS.
This is a transcript of a 7 minute talk I was invited to give at the Cardiovascular and Interventional Society of Europe’s [CIRSE] annual conference in Barcelona, as part of a session on “Controversies in Standard Endovascular Aneurysm Repair [EVAR] within IFU” [indications for use]. This talk: “NICE guidelines best inform clinical practice”, was one…
Human Psychology, Nobel Laureates and Radiology Demand Management
Demand management; responsible requesting; appropriate referring; clinical vetting. Call it what you like: managing the demand for medical imaging is a hot topic. When it’s cheaper, easier and apparently more objective to get a scan than to get a senior and holistic medical opinion the demand for imaging will only increase. Whether demand management is…
Registry Data and the Emperor’s New Clothes
Registries. They’re a big thing in interventional radiology. Go to a conference and you’ll see multiple presentations describing a new device or technique as ‘safe and effective’ on the basis of ‘analysis of prospectively collected data’. National organisations (eg. the Healthcare Quality Improvement Partnership [HQIP] and the National Institute for Health and Care Excellence), professional…
Risky Business
When did you last make a mistake? Maybe you had an accident in the car, left a tap running and flooded the house, made a bad investment. How did that feel? Life if full of risks. We try to engineer them or their effects out as much as possible: we wear seatbelts, lie our infants…
Moral hazard in a failing service
I go to see a woman on the ward to tell her that, again, her procedure is cancelled. I see, written in the resigned expression on her face, the effort and emotional energy it has taken to get herself here: arrangements she made about the care of her household, relatives providing transport from her home…
Decisions, QALYs and the value of a life
Here’s a well known thought experiment: A runaway train is on course to collide with and kill five people who are stuck at a crossing down the track. There is a railway point and you can pull a lever to reroute the train to a siding track, bypassing the people stuck at the crossing but…
Consent and shared decisions
I go to consent a man for an angioplasty. He had a full length stenting of his SFA twelve months ago. This was difficult, required several attempts over a few days and multiple punctures into the artery at the groin, behind the knee and at the ankle. The procedure was done to treat an ulcer…
Resilience
I’ve always thought of myself as stoical and unflappable. I’ve never really engaged with resilience programmes, but I finished rewatching the first series of Cardiac Arrest. The final episode is harrowing and at the end, alone in the darkened living room, the rest of the family asleep, I found myself weeping, uncontrollably, silent tears streaming…
In praise of doing nothing
“Don’t just do something, stand there” A man in his early 80’s is diagnosed with a large hepatocellular carcinoma. This was detected incidentally on an abdominal ultrasound performed for an episode of renal colic. The liver lesion is completely asymptomatic. The ultrasound prompted an MRI of the liver, then a staging CT, a visit to…
What do we mean by need?
The NHS Constitution states that access to its services should be based on clinical need and not on an individual’s ability to pay and that the NHS should provide a comprehensive service, available to all. For many people in the UK, these are articles of faith: fundamental organising principles that underpin one of the great…
Some personal reflections on AAA guideline development with NICE
The development of the NICE guidance on the management Abdominal Aortic Aneurysm [AAA] has been a long, drawn out and difficult process. Publication of the final guidance (in Spring 2020) was overshadowed by the immediate (and ongoing) crisis created by the COVID pandemic which meant the revised recommendations did not get the scrutiny they deserved.…
Tips for IR training and beyond unconscious competence
In order to master a skill, a trainee needs to progress from novice, to journeyman to expert (a process beautifully described in Roger Kneebone’s excellent book: ‘Expert. Understanding the path to mastery’). Typically four stages of competence are described: unconscious and conscious incompetence, followed by conscious and then unconscious competence. If you are a trainee,…
PACS: the miracle and misery
I’m writing this sitting at a MacBook Pro, using Pages. The screen is simple and uncluttered, the buttons on the right are clear, and they do exactly what I expect of them. The ways I cut, paste, copy, drag, highlight or format my text are obvious and similar across most of the software I own.…
#IRad, Twitter and the dominant power of an image
Check out my TACE! One of the great things about interventional radiology is the gratifying and instant feedback the imaging gives you. You can see where the blood vessel was leaking, your perfectly placed coil pack (or your embolic agent of choice) and the end result. If you’ve got some nice 3D reconstruction software, the…
Cost-effectiveness, art and science in medicine
I’m consulting with a man in his mid 70s: a retired teacher in an inner city secondary school. He used to smoke, but quit several years ago. He’s otherwise pretty fit: he has never learned to drive so walks everywhere and uses public transport. He is married, and his wife and he are still independent.…
COVID: time to debate our values
For my first post, I’m adding to the thousands of column inches devoted to the COVID19 pandemic. I’m not an epidemiologist, a virologist, a public health expert or even someone whose practice has been substantially affected by COVID19, other than being unable to treat the patients I would otherwise treat, so I don’t claim any…
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AAA Basics Choice Consent Cost-effectiveness COVID19 Culture Doing nothing Economics Error Ethics Evidence Excellence Expert Guidelines Human factors Mentoring NICE PACS Patients Politics Psychology QALYs Quality Radiolgy radiology RCR Reflection Registries Resilience Responsible requesting Risk Social Media Software specialism Training Trials Twitter
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