Thursday, 18 June 2009

Power without responsibility

It's a deadly combination, power without responsibility, as we've seen with MPs' expenses if people are allowed to do what they want with little fear for the consequences then they will behave quite appallingly and unethically. One of the best ways of ensuring high standards in any system is to ensure that those people who are making important decisions are made accountable for them, after all if something goes wrong and no one is at all accountable, then the same errors will continue to made time and time again. What relevance has this for the NHS, quite a lot I would argue.

I had the misfortune of encountering a rather arrogant and obnoxious radiographer the other day. Radiographers are the technicians who take XRAYs, CT scans et cetera. I have to say that most of the standard radiographers I come into contact with are very pleasant people. The problem is that as with all things in the NHS, radiology has started to be dumbed down, some radiographers have now been empowered to actually report XRAYs as 'reporting radiographers'.

Don't get me wrong, radiographers see a hell of a lot of XRAYs and are very good at spotting fractures, better than a lot of doctors in fact. Unfortunately they are not medically trained, they are not radiologists, meaning that they do not have the broad base of knowledge and training that enables them to think outside the box and think of rare pathologies. For this reason 'reporting radiographers' are only allowed to report a very small percentage of the XRAYs that are done. There is still a problem as what happens when a 'reporting radiographer' misses that rare abnormality that a radiologist would most likely have picked up, I get the distinct feeling that they would not be held to account as a radiologist would be.

Radiologists are notoriously cautious because they know how tricky interpreting XRAYs and other tests is, most of the time one can see the obvious answer straight away, however if one just jumps straight in without thinking one would never diagnose the subtle, rare and potentially career-ending-if-missed pathologies. Radiology is like a minefield littered with the occassional career ending mine, most of the time one will be OK skipping through nonchalantly, however if one skips for long enough one is sure to get blown to smithereens.

I have digressed. The point I was trying to make was that the rather obnoxious 'reporting radiologist' was so overly confident because they lacked the knowledge and insight to be aware of their own limitations, they were skipping through the minefield assuming that their luck would hold. The particular one I met chose to take a quick glance at the XRAY, then claim that it was completely normal and should never have been done. I kept quiet and didn't mention that a rather esteemed Consultant surgeon had a very good clinical grounds for performing the XRAY. This is power without responsibility in the NHS, it generates this rank arrogance in the ignorant, it creates a potentially lethal over confidence in those who do not have enough knowledge to realise their own limitations. I could move onto the tale of the osteopath who reports XRAYs and misses bone tumours the size of footballs, but I would want to get sued for insulting a quack would I?


Anonymous said...

X-ray is not an acronym.

David L. Cox said...

"after all if something goes wrong and no one is at all accountable, then the same errors will continue to made time and time again. What relevance has this for the NHS, quite a lot I would argue."

Absolutely agree.

In the case of MMC, senior people such as Liam Donaldson and Carol Black still need to take responsibility. Both can not be allowed to make the same appalling mistakes again!

the a&e charge nurse said...

In the UK it is estimated that, on average, consultant radiologists report between 18 000 and 20 000 examinations a year, which is considered excessive, while in Australia the estimate is 13 000 to 14 000 examinations a year (similar to the number in the United States).

Same old NHS logisitcs I'm afraid, Ferret - too much work for two few (optimally) trained staff.


*cut demand?
*longer waits (for both investigation and reporting)?
*maximising skills/role of non-medics?
*more doctors?

All options have pros & cons.
The 'dumbing down' mantra is an oversimplification of a complex issue - maybe it's time to move the debate on?

Dr Aust said...

"radiographers see a hell of a lot of XRAYs and are very good at spotting fractures, better than a lot of doctors in fact..."


"...they are not medically trained"

Mrs Dr Aust, the battle-scarred hospital medic, says that "in her day" it was standard for the radiographers to send back the radiographs that juniors ordered with with little coloured dots on the x-rays, which meant "I can see a fracture here". This helped the junior doctors with point 1 above. But the formal interpretation of the radiograph was left to the medically trained.

..Which sounds exactly like what you would expect in a system where people had some awareness of what they were good at, and what others were better at, and all helped each other to do a better job and to improve their skills.

Funny, that.

Garth Marenghi said...

Too much work and too few trained staff.

Good old NHS, let's just hand it to the less trained.

If you had your osteosarcoma missed by a radiogrpaher I doubt you'd be quite so charitable.

Whether it be the nurse in the WIC independently diagnosing, the pharmacist examining a chest, etc, it's all the same dumbing down I'm afraid.

the a&e charge nurse said...

Yes, Ferret - like Sally Hurst I admit I would be disappointed if inadequate medical care led to an osteosarcoma being missed, but sadly it does happen.

Have you heard of the phrase horses for courses?
This multi-centered trial found;
Nurse practitioners in A&E are able to interpret radiographs to a standard equal to senior house officers with three to five months' experience. Those nurse practitioners actively interpreting radiographs as part of their role in minor injury units are able to interpret radiographs to the same standard as senior house officers with more than five months' experience.

It goes without saying that in an ideal world all x/rays would be reported by a consultant radiologist but remember this scandal?

"Radiologist Dr Otto Chan has spoken for the first time about the discovery that led to his dismissal. On two separate occasions, some 15,000 packets of films and scans were kept in corridors as the hospital had neither the manpower nor the money to analyse them all. It is estimated that only half of the films and scans were ever seen by a specialist meaning thousands of patients and their doctors will never know whether or not their images showed any signs of disease".

Surely a reporting radiographer is better than stacks of cardboard boxes in a corridor?

Garth Marenghi said...

Not better than a proper radiologist though, and that's the point.

Steve LITTLEFAIR said...

I reported all plain films (except neonates) for 10 years (since 1997) in the UK.
You are talking complete bollox.
I suggest you read the evidence. The danger for patients is nurses reporting without going on a masters level radiology course and junior docs who learn their radiology in med school from surgeons and physicians.
As for surgeons requesting you mean the all encompassing ? perf ? obstruction just to get an abdominal film which in almost all cases is completely worthless!