As requested

http://www.uth.tmc.edu/radiology/exhibits/koenig_wagner/index.html

http://www.fda.gov/cdrh/rsnaii.html

Bear in mind these 'skin burns' are only the outward signs of the
radiation damage - these individuals have certainly now got a reduced
life expectancy due to stochastic effects. i.e. they will all die from
this medical imaging if they don't die from something else first.

A problem here is we are all cr*p at judging risk - and it suits us to
put differing spin on the data depending on who we talk to. For a
patient, concerned with their own health - CT or Fluoroscopy are touted
as 'safe procedures'. For the referrer they are portrayed as 'risky
procedures' that need to be used as a last resort. This gets very
confusing and is hardly transparent... Spin gets us all into trouble
sooner or latter...

A CXR is as risky in radiation terms as eating two bags of brazil nuts,
for example, but to say there are no proven cases of harm is a bit like
holocaust denial...

Your point about 'work avoidance' needs some comment. I agree these
issues of 'making the best use of an imaging department' pre-date
IR(ME)R. But why is 'work avoidance' a bad thing? In health economics it
is *good* to use capacity *efficiently* and not have lots of spare
capacity. So it would seem sensible to avoid some work so that more
important work can be done within a limited resource. Do you not mean by
'work avoidance' not doing as ordered?

Philip

Philip Cosson
Senior Lecturer
Medical Imaging
University of Teesside
Borough Road
Middlesbrough
Tees Valley
TS1 3BA
 
t: 01642 384175
f: 01642 384105
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-----Original Message-----
From: Accident and Emergency Academic List
[mailto:[log in to unmask]] On Behalf Of Adrian Fogarty
Sent: 13 December 2006 08:08
To: [log in to unmask]
Subject: Re: alleged drug ingestion

Quite fascinating Paul. Yes, I never quite understand the "gatekeeper" 
mentality ingrained into imaging practice in this country. As Rowley
points 
out, we don't find the same attitudes in pathology services, even though
the 
risks are far greater. And I disagree that the Australian comparison is
not 
valid (because of differences in radiation protection legislation) as
I've 
noted the same obstructive behaviour with my radiology colleagues for
many 
years, long before IRMER regulations came into force.

As for a "fee per service" approach, I doubt the conflict that Philip 
suggests would prove unworkable; there are many safety-versus-finance 
conflicts in society which work well, probably the best example being in
the 
field of civil aviation. In other words, I doubt there is any problems 
getting a scan in the private sector in this country. Which comes back
to my 
original argument, that obstructive behaviour has little to do with 
radiation protection and much more to do with work avoidance.

Speaking of risks, Philip is correct, although may even have overstated
the 
risk. As far as I'm aware, there have been no proven cases of harm to
any 
patient undergoing diagnostic imaging (notwithstanding the argument that

angioplasty with stenting is not really diagnostic). Perhaps there are a
few 
case study exceptions which no doubt Philip can share with us. And
although 
individual cases are difficult to "prove" one way or the other, it is
widely 
accepted that the radiation doses involved in routine diagnostic imaging
are 
vastly overshadowed by background radiation.

Coming back to Paul, yes, I'm not at all worried about threats, veiled
or 
otherwise. As you say, everything we say on this List is in the public 
domain, and yes, my radiology colleagues are well aware of my views!

AF

----- Original Message ----- 
From: "Paul Bailey" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Tuesday, December 12, 2006 1:28 PM
Subject: Re: alleged drug ingestion

> Totally.
>
> I work in what could best be described as an urban general hospital.
>
> Our ED sees in the order of 50k / year.
>
> We have "no questions asked" access to plain films 24/7; CT from
0800-2300
> each day "no questions asked" other than talking to the booking clerk.
> Access after midnight more problematic, and straightforward access to
MRI
> 0800-1700 M-F.
>
> We get 'hot' CT reporting ie contemporaneous.
>
> Our radiology colleagues are very happy for us to judge the 
> appropriateness
> of imaging according to the patients needs, and we really never get 
> knocked
> back.
>
> We certainly operate in a CT rich environment, and the English RMOs
who 
> come
> across to work with us for a year or so can't believe the contrast to
the
> situation "back home".
>
> PB
>
> -----Original Message-----
> From: Accident and Emergency Academic List
> [mailto:[log in to unmask]] On Behalf Of Adrian Fogarty
> Sent: Tuesday, 12 December 2006 9:11 PM
> To: [log in to unmask]
> Subject: Re: alleged drug ingestion
>
> Well, you've hit the nail on the head Paul. I think the level of poor
> cooperation we find from radiologists in this country has nothing to
do 
> with
>
> IRMER or radiation exposure. It's just plain "work avoidance" if you
ask 
> me.
>
> AF
>
>
> ----- Original Message ----- 
> From: "Paul Bailey" <[log in to unmask]>
> To: <[log in to unmask]>
> Sent: Tuesday, December 12, 2006 12:36 PM
> Subject: Re: alleged drug ingestion
>
>
>> Here we go again.....
>>
>>
>> From an Australian perspective, it's amazing when you start working
with 
>> a
>> "fee for service" (ie paid for each individual test) radiology
department
>> how these concerns seem to evaporate.
>>
>>
>> Paul Bailey
>>
>>
>>  _____
>>
>> From: Accident and Emergency Academic List
>> [mailto:[log in to unmask]] On Behalf Of Vallis, Jacquie
>> Sent: Tuesday, 12 December 2006 8:30 PM
>> To: [log in to unmask]
>> Subject: Re: alleged drug ingestion
>>
>>
>> Whether or not you can abide it, under IR(ME)R, radiology still has
the
>> ultimate responsibility for justifying the use of radiation to
patients.
>> As
>> I have said already, the main problem is the minimal information on
the
>> request in the first place.  If there can be no justification made
from
>> the
>> information on the request, then radiology will just keep bouncing it
>> back.
>>
>>
>>
>> At the end of the day, it should all be centred around what is best
for
>> the
>> patient, and that is why everyone should work together as a team in
the
>> hospital.  The lack of respect for other specialities such as
radiology 
>> is
>> astounding, and I'm sure that my radiologist colleagues would be
>> interested
>> to hear your views.
>>
>>
>>
>> Jacquie Vallis
>>
>>
>>
>>
>>
>>
>>
>>  _____
>>
>> From: Accident and Emergency Academic List on behalf of Adrian
Fogarty
>> Sent: Mon 11/12/2006 23:49
>> To: [log in to unmask]
>> Subject: Re: alleged drug ingestion
>>
>> ----- Original Message -----
>>
>> From: "Vallis, Jacquie"
>> I do dispute the comment from someone that radiology has no clinical
>> responsibility for the patients, as that was a completely unfounded
>> comment.
>> Radiology sees patients from the entire hospital, not just the A&E
>> department. [Jacquie Vallis]
>>
>> What I actually said was "radiologists don't have primary
responsibility
>> for
>> patients" but since you brought it up I'm happy to clarify, and
maintain
>> they have no direct clinical responsibility. They do have
responsibility
>> for
>> their reporting decisions, and can be held liable for reporting
errors,
>> but
>> that is not the same thing as direct clinical responsibility.
>>
>>
>>
>> And it has nothing to do with patients from other parts of the
hospital 
>> as
>> you suggest. The same thing applies: all patients who undergo imaging
are
>> referred from direct-care clinicians, who take ultimate
responsibility 
>> for
>> their patients' management. Radiologists don't, and what I can't
abide is
>> radiologists - or radiographers for that matter - trying to impose
their
>> views on patient management on to referring clinicians, particularly 
>> since
>> the former (i.e. radiologists) are no longer in clinical practice.
>>
>>
>>
>> Adrian Fogarty
>>
>>
>>
>>> No, it is the concept of "refusing" that does not facilitate good
>>> relationships between departments. Fine, I don't mind a radiologist
>>> (or radiographer) suggesting a different imaging strategy, or I
don't
>>> mind a radiologist (or radiographer) asking for more detail on a
>>> request form, but I don't accept a radiologist (or radiographer)
>>> refusing a request because they don't believe it's indicated.
>>>
>>> That's my job, to decide if someone has sufficient clinical evidence
>>> to warrant imaging, not the radiologist's job. Just this week a
>>> radiology reg tried to persuade my reg that a CT head was not
>>> indicated. Fine, it was a very borderline request and both
registrars
>>> suspected it would be negative, but ultimately it's my registrar's
>>> call, not the radiologist's. My registrar has ultimate
responsibility
>>> for the patient, not the radiology registrar.
>>>
>>> Put it this way, when the debate had reached an "impasse", my
>>> registrar - rather than simply accept the radiologist's advice not
to
>>> scan - held firm in his request for a scan. The impasse was finally
>>> broken when my registrar calmly suggested that since he still wanted
>>> the scan then he would have to document that the radiologist had
>>> refused the scan. The radiologist immediately then acceded to my
>>> registrar's request.
>>>
>>> The bottom line was, that once we record that the radiologist has
>>> refused the scan, then they have to accept a share of the
>>> responsibility for the patient, and they were not prepared to do
>>> that. I thought this was quite illustrative. Radiologists are happy
>>> to try to persuade us that the scan's not needed, but only insofar
as
>>> we change our mind and so we take responsibility. But if you ask the
>>> radiologist to share some of the responsibility, then they're not so
>>> keen to refuse to scan.
>>>
>>> At the end of the day, radiology is a "service" specialty, not much
>>> different from pathology or neurophysiology or any other service
>>> specialty. By that I mean that radiologists' workload is determined
>>> by referring specialists who in turn have primary responsibility for
>>> patients. Radiologists don't have primary responsibility for
>>> patients; their only responsibility relates to the exigencies of the
>>> imaging modality itself.
>>>
>>> So, at the end of the day, you may feel more comfortable making a
>>> distinction between "requesting" and "ordering" but I can tell you
>>> now, when a senior clinician "requests" an image, it's a lot
stronger
>>> than a polite "request", and more often than not for practical
>>> purposes he's "ordering" it. I know you folk aren't comfortable with
>>> that concept, but that's the reality of the situation.
>>>
>>> I suspect a lot of this has got to do with semantics: "request"
>>> suggests subservience while "order" suggests dominance. Perhaps we
>>> should use the more neutral phrase "to book a scan" which more
>>> realistically describes what's going on.
>>>
>>> Adrian Fogarty
>>>
>>> --
>>> *Included Files:*
>>> am2file:001-HTML_Message.html
>>
>>
>> /Rowley./
>>
>>
>>
>>