Several months ago, I read an excellent book by Robert Wachter: The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age. I had been struggling with burnout as the president of my radiology group and had been working hard with Dike Drummond, a doctor who helps other doctors deal with burnout when one of the chapters in the book truly struck me. Almost everything I was reading was an aha moment.
I clearly remember why I chose radiology as a profession. It was during my fourth year of medical school after I had finished rotations in Emergency Medicine and Orthopedic Surgery (my top two choices for residency) when I began my radiology elective. For me, it was the pinnacle of everything I enjoyed about medicine. I truly loved the idea of having a breadth of knowledge covering all areas of medicine while interacting with all my clinical colleagues on a daily basis. As described in the beginning of Wachter’s book, the radiology department seemed to be the one place where every medical specialty came through during the day to consult with the radiologists. All physicians and patients gained immensely from this exchange of knowledge.
Then came PACS…
As I progressed through residency, these exchanges continued. In fact, the on-call residents’ reading room was centrally positioned in the x-ray department right next door to the emergency department. On busy nights, most interpretation of films was done with other physicians standing right next to you.
It was during my last year of residency that a rudimentary Picture Archiving and Communications System, also known as PACS, came to my hospital. PACS allows imaging studies to be read on computer screens rather than printed film. By rudimentary, I mean we could ask the CT technologists to put a case on the computer for us to scroll through the images while the case was still printed separately and hung on light boards for review with our attending in the morning.
What a boon we all thought. To be able to scroll through hundreds of images in seconds, concentrating on each body part, really allowed pathology to almost “pop” out at you compared with moving from picture to picture on a light board. It significantly decreased the amount of time it took to read each case while at the same time increased our sensitivity for pathology. Other benefits included actually placing a cursor on pathology and using digital tools to get rapid density measurement to discriminate water from protein or blood or quick measurements of the size of a tumor, for example. Compared with film readings, which require grabbing a caliper to measure a lesion to compare it to the grid line ruler on the side of the film, this was much easier and faster.
As I progressed to fellowship, this feeling of accuracy and efficiency continued with my new training program’s radiology department being completely digital (also referred to as filmless). In fact, the residents at this program had learned to read exams only on computers. And when we received printed film from outside hospitals for second opinions, I had to teach them how to measure “the old way” with calipers. I was unaware of the gradual decrease in face-to-face consultations as I was at a tertiary care center with residents and fellows in other specialties moving through the radiology department each day, as well as weekly multispecialty conferences that allowed for cross-specialty interaction.
The onset of isolation
It was upon entering private practice in a medium-sized hospital in a medium-sized city that the full impact of PACS on my profession started to become clear. I loved everything about my new job: location, technology, fantastic coworkers, and salary. I felt like I had hit the jackpot. Even though my practice was almost completely digital, I hardly noticed the increasing isolation as we practiced in only a few locations and spent most of our days working together in one reading room with occasional days spent alone at an imaging center.
In addition, our group worked very hard to combat the side effects of digitization of our specialty, such as commoditization, decline in professional satisfaction, and loss of the benefits to patients and physicians of case review and discussion. We have a great “can-do” culture, which has led to us being physically present in our largest hospital 24/7 and performing enormous amounts of interventional procedures such as biopsies, abscess drainages, tumor treatment with embolization, and so forth.
We participate in the usual hospital conferences such as tumor board and trauma conference. In addition, we have created several multispecialty conferences for case discussion such as gastroenterology, orthopedics, neurology/neurosurgery, and pulmonary. The benefits of these interactions to patients, other hospital physicians, and our own physicians cannot be overstated. I can’t even begin to count the number of times those interactions with patients or physicians led to a change in patient care—not to mention the immense professional satisfaction from those interactions.
However, the rapid march of technology continued. As our hospital and imaging centers grew, technology allowed us to cover more locations and more volume without the need for an equal increase in physicians. Over the years, this has led to increasing isolation. Now, rather than cover 1 location with 8 physicians and 2 locations with 1 physician each, we could cover 1 location with 4-5 physicians and 9 locations with only 1 physician each.
There was another (unintended?) consequence of digitization and increased efficiency: Along with the increased isolation, volumes have skyrocketed. As an example, many admissions to the ER are referred almost automatically to radiology, with only a cursory or no physical exam—a consequence of physicians reacting to their own increasing time pressures. This has created a silent pressure to “get back to the work list,” thus decreasing interaction time with patients and referring doctors. In addition, the remoteness of many locations has led to the loss, for many of us, of the ability to attend conferences. This has had implications for us as individuals and was, I now realize, a big factor in my burnout. I can now work for days, and sometimes weeks, without seeing another physician. The occasional instant messaging with coworkers and phone calls with clinical colleagues is all that is left many days.
The impact of unending pressure and isolation
This has to end at some point as the human mind and body, as was thoroughly documented in psychological and neurobiological studies, weren’t meant to handle this kind of unending pressure and isolation. The solution for me has entailed cutting back on work hours and slowing down to spend more time with patients. I also make every effort to let our clinical colleagues know that interacting with us is valuable and not something that should be easily pushed aside by just reading the “message in the bottle” (our radiology report).
As an aside, cutting back on workload is a “high-quality solution to a high-quality problem,” as they call it in management science. What about the millions who are affected by automation and digitizations and cannot afford to cut back? Not just factory workers, but also accountants and lawyers, and yes, physicians in all specialties.
I do believe the introduction of Watson as well as other technology into medicine is a threat to an important part of my practice, the interpretation of films. Will it happen during my career? I don’t think so but it could be close. I imagine I will get to see some of the initial proposed benefits of these new technologies, such as using computers for some of the mundane tasks of serial measurements of pathology and highlighting of variances detected on films. I also think that technology that mines valuable clinical data relevant to my case and presented to me in an easy to access form while reading a case will be beneficial. The other part of my practice, performing various interventional procedures, such as biopsies and abscess drainage, will likely not be replaced with technology for quite a long time (I hope, but who knows). As a leader in my field, Lawrence Muroff, MD likes to say:
“The future for radiology is bright, the future for radiologists is far less certain.”