Sunday, March 16, 2008

Light and Dark: Surgeons, Radiologists, and Why They Need Mutual Understanding to Succeed

Douglas P Monroe MD, LRCP&SI, Beth S Edeiken-Monroe, MD, FACR, and Nancy D Perrier MD, FACS

In many ways, surgery and radiology embody opposites. The surgeon usually practices at the top of the hospital in daylight amplified by bright OR lights and glaring headlights. Radiology reading rooms are often dark caverns lit solely by unnatural fluorescence filtered through dim transparencies. Imagers conduct business at sub conversational volumes, quietly whispering specialty secrets to their students and dictating machines. In contrast to the quiet of the reading room, operating rooms are filled with the sounds of buzzes, beeps, whines, and whirs. Notoriously, surgeons do not “whisper the secrets” of their profession; more often, they loudly proclaim them at their students and then wonder why no one knew them in the first place.

These differences are not limited to traditional stereotypes. Surgery is an ancient art, and appears to have been around since prehistory in the form of trepanation.(1) In contrast, Roentgen won the first Nobel Prize in Physics for discovering the x-ray just over 100 years ago. Surgeons serve patients via direct referral, while radiologists provide service to another physician. In the majority of cases, radiologists never actually meet the patients they are serving. The surgeon, on the other hand, not only meets the patient, but becomes intimately familiar with their exterior and interior. The goal of radiology is most often diagnostic; the goal of surgery is most often therapeutic.

There is no doubt that in a minority of cases these two specialties have begun to overlap. There are now surgeons who interpret images and radiologists who perform intervention. For example, intraoperative CT and US equipment is increasingly available to the surgeon for interpretation, and mini operating rooms with anesthesiology support are provided for radiologists with interventional skills. The resulting friction can cause rifts between medical professionals who see themselves in competition for resources and patients. While we do not propose a solution to these dilemmas, we do seek to define the important nature of the relationship between surgeon and radiologist in a majority of cases.

Despite their differences surgery and radiology share a fundamental commonality that inextricably links them; both require detailed knowledge of anatomy to be successful. This bond is accentuated because procedures with minimal exposure rely less on intraoperative gross inspection and more on preoperative planning based on imaging interpretation. Thus, the advent of minimally invasive procedures necessitates a professionally intimate relationship between surgeon and radiologist.

Surgical grand rounds and multidisciplinary conferences have long provided an educational opportunity that transcends the science of medicine. For the inexperienced medical student, these meetings may seem to be little more than a battle of egos. A more astute student may recognize that the often-contentious tone of these meetings has less to do with ego and more to do with the nature of the questions and answers originating from each side. The radiologist seeks accurate interpretation of the images, whether definitive or equivocal. The surgeon seeks definitive answers to whether, where, and how to perform surgical intervention. Both approaches are correct when we consider the nature of the two disciplines: diagnosis and therapy. Mutual recognition of these different approaches can lead to successful interdisciplinary communication, integration, and most importantly, appropriate treatment of the patient.

Effective communication is increasingly cited as the key to successful practice and the avoidance of legal action.(2) Medical professionals who are skilled communicators are more likely to have compliant and satisfied patients.(3) Therefore, it is not difficult to extrapolate that good communication is effective not only between physician and patient, but also physician and physician. When the surgeon questions or criticizes the interpretation of the radiologist, or vice versa, the criticism must not be construed as a personal attack. Good medicine requires that ego and competition be superseded in the best interest of healing the patient.

In the current era of minimally invasive surgical intervention, level 1 trauma centers, percutaneous cryoablation, and radiofrequency ablation, the success of both radiologist and surgeon are linked. One discipline cannot fully succeed in benefiting the patient without the other. Success relies upon integration of the two disciplines through clear and open communication and the exclusion of personal or professional self-interest.

Western philosophy is rooted in the study of dichotomy: the tension that exists between opposites. As it often is with the brilliant Greek philosophers we find ourselves, in spite of our advanced technology, defined by their ancient tenets that preceded our bovies and MRI machines by millennia. As it was in the past, so it is with surgery and radiology today. One cannot exist without the other. In short, light is defined by dark, and dark is defined by light.

1. Verano JW. Trepanation in Prehistoric South America: Geographic and Temporal Trends over 2,000 Years. In: Arnott R, Finger S, Smith CUM, eds. Trepanation: history, discovery, theory. Lisse, The Netherlands: Swets & Zeitlinger; 2003:223-236.
2. Colon VF. 10 ways to reduce medical malpractice exposure. Physician Exec. 2002;28(2):16-18.
3. Kotegawa T. Communication skills for pharmaceutical care. Yakugaku Zasshi. 2007;127(2):237-244.

Print Publication:
J Am Coll Surg. 2007 Dec;205(6):805-6. Epub 2007 Sep 17.
PMID: 18035265 [PubMed - indexed for MEDLINE]


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