ISSN:0004-8461    

DOI:10.1111/j.1440-1673.1973.tb01445.x

出版商:Blackwell Publishing Ltd    

年代:1973

数据来源: WILEY

ISSN:0004-8461    

DOI:10.1111/j.1440-1673.1973.tb01446.x

出版商:Blackwell Publishing Ltd    

年代:1973

数据来源: WILEY

摘要:

SummaryTeaching and organizing radiology in a new medical school provides the opportunity to emphasize that radiologists are doctors to whom patients are referred for an opinion, and not photographers. Emphasis has been placed on the need for clinical consultation, clinical responsibility, and only lastly on issuing reports.In the medical school, radiology is taught early in the first year and throughout the curriculum. All Radiology has become the responsibility of the radiologists, both in the hospital and on the campus. They have much to offer in anatomy, physiology, clinical medicine and research.About five years ago, the University of California started a new medical school on the Davis campus in Northern California. When Dr. John Tupper, M.D., was appointed Dean, he found nothing but a wide open space and instructions to build a new medical school “as soon as possible, as good as possible, and costing as little as possible”. As if this was not enough, the new school had to be “fresh in outlook”.The progress he made was remarkable. Staff were recruited, and the medical school was started. Not the huge monument of brick or stone so often thought essential to status, but modern temporary buildings: they look simple from the outside, but they are sophisticated within. There are libraries, lecture halls, laboratories, and, inevitably, administrative offices. They grew rapidly and have gone on growing in size, number, and complexity. Within them, fifty medical students started four years ago and will graduate in 1972. Money was spent on facilities for learning and teaching, rather than on buildings. The Dean has taken his medical school from nothing to an annual intake of 100 students and done it in five years. This is a record of achievement.The clinical needs were met in the Sacramento Medical Center, leased from the County of Sacramento. By now, there are 165 registrars and house officers in training in the University Hospital, and the Department of Radiology‐there carries out between 70,000 and 80,000 examinations every year. It was only some eighteen months ago that Dr. A. Raventos, M.D. was appointed as radiotherapist and Chairman of the Department of Radiology. I joined him as Head of Diagnostic Radiology, and we found that we had three full‐time radiologists to look after the 200 patients who came every day through our six available X‐ray rooms: we had a twenty‐four‐hour service with a big emergency load. There were no facilities, no registrars, and no shortage of problems.If the motto of the medical school was “Be Fresh in Outlook”, we certainly faced a situation which was far from the usual state of affairs in a University hospital. There was no way in which we could set up “instant” radiology: this meant that we had to look carefully at our basic philosophical approach, to list our priorities and then to apply them. Maybe this was a good thing ? Perhaps we do not do this often enough ? It has certainly been an interesting experience which has a long way to go before it is finished.In the hospital it was quite obvious that the available radiologists could not report on nearly 80,000 examinations yearly. In fact, there was hardly time to report on anything. Our most basic belief was that radiology was for the radiologists, and this meant that our first task was to take over all radiological examinations. That was the first major and radical change: until then, many studies of all sorts had of necessity been carried out by other departments. We decided that if we were going to have a good Department of Radiology, with good radiologists, then we alone must be responsible for everything radiological. This does not mean the exclusion of others from the Department of Radiology any more than radiologists are forbidden to go into the hospital wards. But it does mean that the ultimate responsibility for the whole of radiology must lie with the radiologists. And if this is to be so, then radiologists must remember that they, too, are doctors who practise medicine.It is only too easy in the rush of a busy radiological department to believe that issuing a “report” is the radiologist's first responsibility. On consideration, maybe it is the last of his duties ? His first task should be to help the patients referred to him. Having decided this and to establish the basis on which we wished to work, we made it clear that we would not accept any “orders” for X‐ray examinations, but we would be happy to accept “requests”. We wished patients to be referred to us in consultation as they are to any other specialist, and not to have “photographs taken”.In any department of radiology there are many examinations which are routine. A patient with a cough will need his chest X‐rayed. Most X‐ray requests fall into this category, but there is a very significant number in which the radiologists should be consulted. He must therefore be aware of the patient's complaints and the clinical findings and of the clinician's difficulties. He can then take some valid part in deciding whether the next examination should be a barium meal or a barium enema for that particular patient. Only too often this decision is left to a junior house officer, on the theory that it teaches him responsibility. But how can one learn to make a correct decision without adequate knowledge? Teaching the worried house officer to take his diagnostic problems to the radiologist, and getting the radiologist out of his office to face the clinical problems might be a better approach. Investigations become more useful, and as a result, expensive and time‐consuming studies can often be avoided. Ask the house officer if he personally would like to to have an unnecessary barium enema, and pay for it, to satisfy someone else's curiosity and maybe his request will become a little more thoughtful. Nor can the risks of radiology be ignored. Sometimes radiology is regarded as no more than an auscultation of the chest, yet the dangers of contrast examinations are statistically evident, and the debate on radiation hazards has by no means ended. Responsibility must include an awareness of all these factors and of the benefits which may result from undergoing such risks. That, too, is the task of the radiologist: he should not merely report on the beautiful pictures which result. It goes without saying that to challenge the right of a clinician to “order” any examination for his patient is almost as bad as suggesting he does not know how to interpret the radiographs which result. The response is likely to be reflex rather than considered, explosive rather than calm, and even physical rather than mental!Nevertheless, the clinician must be taught his lessons. Firstly, the patient needs the maximum of expert help available, which means a radiologist and a clinician working together: secondly, that the radiologist is in his own way just as good a doctor as any clinician. His training is at least as complex and as difficult as that undergone by any surgeon or other specialist. (I choose to mention surgeons as an example because they seem to give themselves a closer relationship to the Deity than most, but there are exceptions to every rule!) The best interest of the patient demands that every specialist concerned shall be fully aware of the clinical problem and shall have every opportunity to give his advice and opinion after proper consideration and with a full sense of personal responsibility.I would not like to give the impression that we do not write reports: we do so in ever increasing numbers, but we believe that any report which is not available within a matter of hours is a waste of time. Eventually, we must get the reports out with the X‐ray films so that both may be seen together, because this is the only way in which they will be read. All the reports are brief, and radiologists are expected to give a firm, and, if possible, definite opinion. Almost anyone can list the differential diagnosis and claim that he was right. However, this outlook does not help the patient or the doctor, and it inevitably results in the radiologist acquiring disrepuis own doctor may help him further. Sooner or later, someone has got to make a decision and label the disease so that it can be treated. This responsibility is just as much the radiologist's as the clinician's, and he should not be afraid to take part. It may be necessary to list a number of alternatives, but the better the clinical information the shorter the list will be. Sometimes, the radiologist cannot give a definite answer, and he should then say so without hesitation. If his reports are either positive, or negative, or firmly undecided, his reputation will grow and be trusted. No one should be afraid of making mistakes: we all do it, and from them we learn.How do you bring about such a transformation? How do you do it in a medical school which has been working for two or three years without university radiologists, with clinicians who have been educated in other medical schools where this philosophy may not have been apparent? We tried to solve it by communication. We tried to be available to talk to doctors about their patients. We restricted the availability of X‐ray films to a room within the Department of Radiology to which all doctors could come to see those belonging to their patients, and at the same time consult with the radiologists. Sometimes in the beginning, the radiologists had to listen unasked to the opinions being offered. It was seldom difficult to point out something or to correct an impression and thus to establish one's right to be heard. In fact, I would say that it is never difficult for a competent radiologist to add to a clinician's interpretation of an X‐ray film, and that he can almost always do this better in consultation than he can by writing a report.For one whole month in the beginning I personally made all the appointments for any examination which required the direct contact of a radiologist. At the same time I saw every request slip through the Department, and I returned those which did not give me sufficient or satisfactory information. I did so, well aware of the delay which this caused, but believing that it was in the long run in the best interest of the patients. Slowly, as the staff of the Radiology Department increased in numbers, they took over almost all the examinations. We are not yet fully, or adequately staffed, and so there are fields in which we still welcome the help of the clinicians: but this does not absolve us from the responsibility for the patient undergoing a radiological examination or for the way in which it is done.We have brought medical students into the Department to spend an elective period of five or ten weeks with us. During this time, they not only see as much work as possible, but (and perhaps of more importance) they can talk to the radiologists, listen to their thoughts and watch the way in which they work. We welcome house officers and registrars from other departments for similar training, and the numbers are increasing. Whatever they may learn about radiology is an added bonus to the realization that radiologists are people: doctors, not technicians.This year we started training our first registrars in radiology. We are trying to instil into each and every trainee the realization that he is a doctor, that he is still looking at patients, even if he only sees an X‐ray film. It is called moral and legal responsibility and it makes a great deal of difference to one's reports.As part of the communications process, and because we were very short of staff, we established meetings with as many departments in the hospital as possible. We review their current films, we discuss their problem cases, and on some occasions provide demonstrations of particular diseases or syndromes. These are always Chaired by a radiologist, and seldom does he look at an X‐ray film without being given the clinical information first. The challenge to look at it “as an X‐ray film” is refused. It is not simply a film or an exercise in observation, but it is one method of examining a patient and it should never be viewed in isolation.I would not like to suggest that all this has been carried out smoothly: no radiologist would believe me, nor do I have to fill in the details! I cannot claim that the system never fails. It will not work properly until we have a large enough group of radiologists and have established ourselves for some years. Nevertheless, it represents our “fresh outlook” in the approach to radiology. There is really nothing new about it. It was born of necessity and grew from a deeply felt belief that radiologists are almost always good doctors, but because of events, the over‐emphasis on the written report and the enormous amount of daily work, they have often been pushed back into their offices and thereby done themselves and their profession much harm. The ultimate example of the process is the Chairman or Director of Radiology, who was originally appointed because he had (hopefully) a reputation for being a good radiologist. In any big department he becomes so remote from his patients and his X‐ray films that his professional ability declines and he becomes office‐bound, both physically and mentally. There is one worse fate: he becomes a good committee man and believes that by doing so his department benefits. Perhaps he is not far wrong, because by then he is often safer on a committee than in front of a viewing box: but this is not why he was made the Chairman.Escaping from such dignified heights and returning to being a radiologist is not easy: I know. Maybe that is why I am trying to prevent any radiologist from forgetting that he is a doctor first, and equally important, I am keen that no clinician be allowed to forget that fact either.Any other approach to radiology, any acceptance that examinations should be carried out because of the ignorance of the referring clinician and not because of the need of the patient: any attempt to escape responsibility, or any belief that one can issue reports which are available three weeks later, and that this is being a good radiologist, only suggests to me that the individual does not really want to be a doctor and thought that radiology was the easiest and least tiresome (and sometimes the most well‐paid) post available.While all this went on in the hospital, we became involved in the teaching of medical students. I let it be known that I would be available and that I would be happy to teach. Indeed I put forward the philosophy that anything radiological belonged to the radiologists in the medical school just as much as it did in the hospital. What is more, I said that we had a lot to offer in terms of anatomy, physiology and similar studies. It is amazing how many clinicians regard a barium meal as a static picture of the stomach from which a firm diagnosis can be made simply by viewing the outline. It takes a long time to teach them that it is a mobile bag, distorted by inner movement, by panic, by respiration, and even by the patient's position. The message should be started in the medical school: the simple one that radiology is in essence only another way of examining a patient, that it provides not only clinical knowledge, but quite often the only way of studying the natural history of a disease. Examples are so obvious that they hardly need quotation. The rapid response to drugs of a lung infection, the two‐year span of Perthe's disease of the hip joint, the whole gamut of any inflammatory arthritis from start to finish, or the natural process of ankylosing spondylitis over many years: all these can be studied radiologically, and therefore, can be taught in the same way. I am not convinced that it is necessary to teach students any significant amount of physics, photographic chemistry, or anything of a technical nature, provided that they can be made aware of the significance of varying density, overlying shadows and physiological and anatomical variations. In the Medical School, they can be introduced to all that vast intimate knowledge of the human being which is the daily work of the radiologist, and their respect will grow alongside their knowledge.Thus, at Davis the radiologists teach duridical School as well as in the clinical subjects. I have even found myself back in the dissecting room, a very educational process for me at least. Combined teaching is the rule here, based on a systems‐oriented core syllabus. This means that radiologists will have to spend more time teaching than is usual, but whatever they say is likely to have more significance. Surely the days when one could talk for hours on the radiology of the colon in isolation from any other subjects should have disappeared? One can hardly expect a student to remember and separate all those different changes which can be found in the multiple diseases affecting the bowel. But if a clinician tells him about a patient with ulcerative colitis, and then the pathologist demonstrates what the colon will look like both macroscopically and microscopically, it is easy for the radiologist to follow and show clearly the pathological changes to be seen on the X‐ray films of such a patient. It is an education for the radiologist himself to relate his detailed findings to those of the pathologist, and to become aware of how closely linked they can be. The student learns that we are all talking about the same thing: he does not have to learn clinical medicine first, then pathology as a separate subject, and add to it radiology, pharmacology, and all those other specialities.I think that a radiologist should be able to look at an X‐ray film and tell the pathologist what he can expect to see, and tell the clinician what the patient may feel; and if teaching is done this way, the student will accept it more readily. Much time has got to be spent on this, not only in the preparation of each lecture, but in co‐ordination with the others taking part in the actual presentation. Much can be added by the use of videotape, audio‐visual aids, and teaching with slides, but nothing takes the place of the teacher himself.All these methods can be brought together when six or eight students sit down with a radiologist and look at X‐ray films. They interpret them, answer questions, and are led as the discussion progresses to learn both normal and the abnormal. This, too, is very time‐consuming and requires a large number of radiologists in the medical school when such sessions are arranged, but it also serves a double process. It reminds the radiologist once more that he is not an isolated being in a small office attached by one hand to a dictaphone, but is a teacher, a doctor who has something to impart to his students who in turn will ask him questions which he cannot answer: and this is always good for his soul: perhaps it will surprise some clinicians to know that a radiologist has a soul!That is the pattern we hope to establish at Davis: doctors who are radiologists, or if you prefer it, radiologists who are doctors. The order of significance is insignificant, but both parts are essential if the whole is going to be any‐good. That this will produce a better standard of academic and clinical radiology, we are convinced. That it will give us many headaches at the same time, we have already learnt. But at least none of us can complain either of boredom or of a well‐es

ISSN:0004-8461    

DOI:10.1111/j.1440-1673.1973.tb01447.x

出版商:Blackwell Publishing Ltd    

年代:1973

数据来源: WILEY

摘要:

SummaryA technique is described which purports to allow a high dose of radiation to be given to pituitary adenomas, with safety.The anatomical basis for the treatment plan is discussed.

ISSN:0004-8461    

DOI:10.1111/j.1440-1673.1973.tb01448.x

出版商:Blackwell Publishing Ltd    

年代:1973

数据来源: WILEY

ISSN:0004-8461    

DOI:10.1111/j.1440-1673.1973.tb01449.x

出版商:Blackwell Publishing Ltd    

年代:1973

数据来源: WILEY

摘要:

SummaryA retrospective analysis of the experience of the Radiotherapy Unit in General Hospital shows a high incidence of cancer of the nasopharynx amongst the Chinese and a medium incidence amongst Malays. There does not appear to be an increased frequency among Indians. There is a suggestion that the disease is of lesser frequency than in Hong Kong, and this may be partly due to the reduction in the intensity of carcinogenic stimulation. Further investigation is required.

ISSN:0004-8461    

DOI:10.1111/j.1440-1673.1973.tb01450.x

出版商:Blackwell Publishing Ltd    

年代:1973

数据来源: WILEY

ISSN:0004-8461    

DOI:10.1111/j.1440-1673.1973.tb01451.x

出版商:Blackwell Publishing Ltd    

年代:1973

数据来源: WILEY

摘要:

SummaryTwo patients with Fallot's tetralogy and hypertrophic osteoarthropathy are reported. The possible causes of this condition are discussed.

ISSN:0004-8461    

DOI:10.1111/j.1440-1673.1973.tb01452.x

出版商:Blackwell Publishing Ltd    

年代:1973

数据来源: WILEY

ISSN:0004-8461    

DOI:10.1111/j.1440-1673.1973.tb01453.x

出版商:Blackwell Publishing Ltd    

年代:1973

数据来源: WILEY

摘要:

SummaryPercutaneous transhepatic cholangiography is a procedure that can be readily done in most radiological departments. Prospective study was made of 95 examinations to assess the success rate, tolerance of the patient to the procedure, complication rate, diagnostic value and indirect value of a failed attempt as indication of absence of extrahepatic obstruction. A hypothetical intrahepatic duct width of 5 mm. is taken to represent the normal mean between the right and left hepatic ducts. In patients with intrahepatic duct width exceeding 5 mm. nearly 100% success rate of puncture can be obtained. With an intrahepatic duct width of 5 mm. or less nearly 50% success rate is achieved. The tolerance of the patient is good and complication rate low. The risk incurred is justified by the benefit and help from a successful cholangiogram which has a high index of diagnostic accuracy. In experienced hands a failed attempt is a reliable indication of absence of extrahepatic obstruction.

ISSN:0004-8461    

DOI:10.1111/j.1440-1673.1973.tb01454.x

出版商:Blackwell Publishing Ltd    

年代:1973

数据来源: WILEY