RADIOLOGISTS

PERSPECTIVE

Dr. ANTHONY HANBIDGE

Dr. Anthony Hanbidge is a diagnostic radiologist at Toronto Western Hospital and an associate professor of medicine at the University of Toronto. He meets with Dr. Ho Ping Kong every Wednesday afternoon to discuss imaging studies from Dr. Ho Ping Kong's internal medicine clinic.

Raised and educated in Ireland, Dr. Tony Hanbidge practised family medicine in the.small town of Botwood, Newfoundland (population about 3,000), for eight years. "It was fulfilling, but all consuming," he says. "You were never off call. Everyone knew you and where you lived. That's good and bad. You were expected to be always available."

At 30, Hanbidge decided to specialize. He thought seriously about internal medicine. "The idea of disease as a puzzle that had to be solved appealed to me." But he ultimately settled on radiology, because he had developed something of an expertise at Botwood Cottage Hospital. "I was particularly drawn to it. Among my colleagues, I had become the go-to person for reading x-rays."

But when he began talking to admissions personnel for specialization programs, he was effectively told, "You're over the hill. Don't waste our time and your money. You probably won't be successful elsewhere, either."

"That motivated me," he says, "rather than discouraged me." 

When he arrived in Toronto in 1990, Hanbidge was stunned to see the degree to which technological innovation had revolutionized his field. "In fairness, I didn't even realize what radiology was. The technological leap was nothing but staggering. Computers were everywhere, and cross-sectional imaging was well established. In 1990, the entire province of Newfoundland might have had two CT scanners, whereas downtown Toronto alone had 10 or 12, perhaps more, plus MRI machines."

For Hanbidge, it constituted a dramatic shift in what he had understood as the practice of medicine. The trend has only accelerated; the use of CT and MRI scans for diagnostic purposes has grown exponentially.

"The technologies are fantastic," Hanbidge acknowledges. As an intern in Dublin, he often assisted at diagnostic laparotomies — exploratory surgery to locate the cause of a patient's pain. "The patient would have had a barium enema, a barium swallow, an intravenous pyelogram and other tests, but in the end, nobody was quite sure what was going on, so we'd say, 'Let's look in there,' and you'd be on the table. You don't see that happening anymore. Technology has delivered the potential for fast and accurate answers."

Today, if a patient presents in a hospital's emergency department with pain in the abdomen or elsewhere, the reflex response is to order an imaging test. In part, that's because of the success of scanning technology in diagnosis. And in part, it's because of the pressures on the emergency department — the overload of patients and the consequent shortage of time. In the past, it was commonplace for surgeons to remove appendixes simply because it was the assumed source of a patient's pain. Today, very few are removed without preliminary imaging studies.

Technology has impacted medical practice in other ways as well. Years ago, if doctors could not diagnose an illness, a patient would often be admitted to hospital and kept under observation. "The thinking was, 'Let's see how he is in six hours or 12 hours or 18 hours,'" says Hanbidge. "You were either getting better, or getting worse or staying the same. Time itself could help provide a diagnosis. Now, using ultrasound, CT or MRI scanners, decisions are made almost immediately, usually before surgeons are consulted. That's a fundamental shift."

But while accurate diagnoses are typically being made much faster, something else, Hanbidge maintains, has been lost — the entire skill set of chatting, listening, observing, assessing, palpating and percussing. "It doesn't happen in the same way," he says, "for better or worse. So those skills often don't mature to the same level." In cases where the diagnosis is clear, this loss is not critical. "With a hot appendix," he says, "the imaging techniques will be right most of the time."

But what happens if and when the diagnosis is not so clear?

"Maybe the illness isn't all physical, but a little psychosocial, some depression perhaps, a family history of something or other. So there is still a need for having a conversation between doctor and patient, a chat with a doctor who looks you in the eye and is actually listening. That feels good when you are patient because you know he cares and he's been caring for a long time — he cares with interest. If you are in the hands of a very experienced clinician who gives undivided attention, that in itself has amazing healing power and potential."

The challenge for medicine, going forward, Hanbidge argues, will be to strike the appropriate balance between the unquestionable benefits of technology and the human factor — the still irreplaceable art of medicine. "There is a danger of weighting it too much on the technology end. The secret is to manage a balance to keep enough time in the system to make a human connection. But if these arts are not taught and learned in the same way by the next generation, if as a trainee I never have the opportunity to apply these clinical skills and make up my mind on that basis, because I know, or I think I already know the answer, then what will happen in the next 10 or 20 years?"

The importance of maintaining the old medical skill set is heightened, Hanbidge believes, by the increasing complexity of modern life. People are deluged by information, not all of which is reliable or true. On the one hand, the birth of internet culture means patients are much better informed about their conditions than ever before. In some cases, he concedes, "they know more about their disease than I do. I'm talking about the rarer conditions. They will have read everything there is to read online, and will be aware of the risks of this or that and are part of a support group with the same or similar ailments."

On the other hand, there is so much information that patients now often form an opinion of their own diagnosis even before they meet the doctor. "It makes it very hard for them to give me an unbiased presentation of their history. They are not lying. But they have self-diagnosed and are emphasizing symptoms that will lead me in a certain direction."

Even the marvels of technology have become, to some extent, a double-edged weapon. "We see lots of stuff on images that are not relevant to your current complaint or future, potential illnesses — lumps and bumps all over the place. So for all the great work we do in solving problems, we also create a lot of problems. We did not find X, but we founds and B and C. What do you do then?"

It was once the fashion, Hanbidge recalls, for senior business executives and professionals to have whole-body screenings. Everyone, of course, is seeking a clean bill of health. One radiologist found a nodule on his lung and was then faced with the question — do I ignore it and wait a few years and see what happens? Or do I intervene now? "So he wanted an answer immediately and had it biopsied. Complications set in. The lung did not expand. Clots developed in the leg and then a pulmonary embolism. Finally, the nodule was removed and turned out to be benign. He'd probably had it for most of his life. He later wrote an article about the experience in which he confessed that he had once been a big fan of whole-body scans, but was now having second thoughts. Aside from the $500,000 he'd cost the health care system, it had not been much fun."

As the population ages, the medical system will be tested in other ways, Hanbidge predicts. "There are collateral considerations that are difficult to sift through. Resources are finite, and there will have to be more discussions about appropriateness criteria, for certain tests. Say you sprain your ankle. When do you need an x-ray and when don't you? Well, we have guidelines for that. Ideally, that would be expanded to other symptom sets. But it is very hard to reach agreement, even in the same establishment."

It's in this context, Hanbidge suggests, that the pendulum may eventually begin to swing back to the art of medicine, if only because the costs of technology become prohibitive. "We have to manage what we have. And maybe the level of care we give to a 92-year-old should be different than the care we extend to a 32-year-old with dependents."

Hanbidge's own father, a farmer, passed away not long ago at the age of 92. In his entire life, he'd been in hospital two days — at age 44 for a hernia repair. "He died at home in the old farm house without a blood test having been done. He was fundamentally intact until three weeks before he died. A family doctor came a couple of times at the request of the children, and a public health nurse came every day for the last 10 days." But not a single diagnostic test was performed, except perhaps using' a stethoscope. "For me, that is completely appropriate," Hanbidge says. "As a culture, we have to be willing to accept that there is a time when dying may not be a bad option, provided it is facilitated with comfort and dignity, and support for the individual and those around him or her. That's a tricky conversation. But maybe that's the real art of medicine, helping people come to terms with death."

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RHEUMATOLOGIST'S PERSPECTIVE

Dr. LORI ALBERT

Dr. Lori Albert is the education/clinical coordinator of the University Health Network's Arthritis Program. She is an associate professor, Faculty of Medicine, University of Toronto. She received her M.D. from the University of Toronto in 1988, completed a residency in internal medicine there in 1991 and a residency in rheumatology in 1993.

When lori albert was A junior staff member in rheumatology at Toronto Western Hospital, she was asked to examine a patient of Dr. Herbert Ho Ping Kong — a young man with an unusual rash. "I think Herbert had already made a diagnosis, but he wanted my opinion," she recalls. "I made a broad differential diagnosis," essentially a way of considering all the various possibilities. "One of them was lupus, but I didn't really think it was lupus, so it wasn't high on my list. Then, HPK came along and said, 'It's lupus.' And I said, 'Well possibly, but I think we need to also consider X and T, and do tests A, B and C. And he said, 'It's lupus.' And of course, he was right, even before the tests were ordered. He just knew, even though it was an atypical case, because it was a man, not a woman. He'd seen it before and there was something he recognized."

Albert already knew Ho Ping Kong, of course, having encountered him at regular sessions of Morning Report, an 8 a.m. medical school gathering where trainees were challenged to figure out a diagnosis of a patient admitted to hospital the previous nights. "The junior resident would parcel out the facts of a case, and HPK would give us cryptic clues that we had to decipher," she recalls. "It was a totally intimidating experience. I remember one case dealt with pulmonary edema, fluid in the lungs, which sometimes makes you cough up blood-tinged sputum. His clue for that might be 'Has anyone been drinking a strawberry milkshake?' But he was very good about praising you if you made the right deduction, and would lead you through your thought process."

Later, Albert says, HPK was responsible for her decision to go into rheumatology. She had planned a career as a hematology oncologist. "I had done all my electives and rotations in hematology and not done any in rheumatology. And one day I was chatting with Herbert, and he said, 'Have you considered rheumatology?'

And I said, 'Not really'

'Well, have you done a rotation in rheumatology?'

'No.'

He said, 'Let me go talk to Rob Inman'" — a senior rheumatologist who had been one of Albert's teachers. "So then Rob came to talk to me, persuaded me to do a rotation in rheumatology and the rest is history. But it was Herbert's talking to Inman that set me on that path."

What appealed to her about the discipline, she says, was the chance to develop longitudinal relationships with patients, since many rheumatoid conditions are persistent. "And there's a lot of uncertainty, which translates into diagnostic challenges, recognizing the patterns in things and putting weird stuff together as a disease. I love that, and sometimes I hate it and wish I were doing something like cardiology, which is more cut and dried. But I like hearing patients' stories, assembling the clues and finding what I hope is the answer. The answer isn't always the one they want to hear, but our capacity to treat many diseases has improved in the last 10 years because of medication. And when the diseases have a lot of morbidity, you have to provide psychosocial support, especially for young women who are experiencing side effects of prednisone that may be disfiguring."

Among the hardest aspects of the art of medicine, she says, is the delivery of bad news. "Some people have an innate ability for it. They are just better communicators, better able to delve into dangerous areas. In a personal context — at a cocktail party, for example — I would never ask a leading, personal question. But in the clinic, I will, and I don't mind if they cry, because it means we've got to the crux of the problem."

The facility is also enhanced, she believes, if the doctor has life experience to draw upon — having been a patient or tending to family members or friends who were critically ill. "It gives you a better sense of how you'd want physicians to relate to you," she says. "I think you need to be empathetic, but also know that people can cope if you present things to them in the right way. You have to be upfront, but you also need to lend support."

Albert maintains that, in her field at least, disease is generally less complicated than in the past, because it is usually identified earlier. "Rheumatoid arthritis, for example, has changed dramatically even from when I interned," she says. "It used to be incredibly disabling and now it isn't. People would be admitted to hospital for two weeks of bed rest and that just doesn't happen anymore, thanks largely to new drugs."

What has become more complex, she says, is its context. "People's lives are more complex today. They are under pressure at work or in other aspects of their lives. They may be self-employed, and earn enough money to not qualify for free medications, but not enough to be able to afford the $18,000 it costs for the biologic drugs they need." Increasingly, the art of medicine today involves helping patients deal with issues that surround their lives, not just the disease itself.

Treatment is also complicated by the variety of choices now available. "The treatments are effective," she says, "but they all come with a menu of side effects. Being able to explain to a patient the relative importance of these side effects is tough, all the more so because they will likely have read something about the disease on the internet and have some information, but not enough." It's another example of Alexander Pope's famous dictum, "A little knowledge is a dangerous thing."

On the other hand, patients often don't want too much information — though physicians are obliged to provide it — because they find too much data overwhelming. "We used to be able to say, 'Just take this and you'll get better,' but now we can't. We have to explain everything and it has to be a mutual decision. And the more drugs they have and the more co-morbidities [overlapping diseases], the greater the difficulty of choosing the right treatment. So that's the complicated stuff."

All of this, inevitably, requires time — more time than the disease itself. On some days, Albert says she functions as much like a social worker as a doctor. "I don't mind that, but it's hard to manage the time."

The reality of day-to-day practice in rheumatology, as in other disciplines, demonstrates again that the neat algorithmic medical school formulae offered up to diagnose and treat disease are not sufficient. "We all love algorithms," she says. "They're so clean, neat and tidy. If this, then that. Ostensibly, it means it's harder to make mistakes, and you are more likely to follow the correct trajectory. But people become very dependent on them and don't see outside of them."

In effect, the increase of algorithmic-based diagnosis and treatment implies a correspondent decrease in independent, critical thinking. "It's a real art to get people to think critically." The other corollary of algorithm-dependent thinking, Albert adds, is that it effectively takes the individual out of the equation. By definition, if you are simply following the logic of an algorithm, the actual patient—with all of his or her nuances and idiosyncrasies — becomes secondary. "Yet more and more, the students want that," she says. "It's on your device, your smartphone or your tablet, and it's easy to follow and you don't have to remember as much."

Moving students off that pathway is difficult, she contends, "because they are so driven to do well on exams, in order to get the residency of their choice, and the position they want." Although she thinks the clinical skills courses — on interviewing, conflict resolution, ethics and dealing with difficult patients, for example — are quite good these days, medical students, to her "seem somehow jaded. They don't always see the value of these courses and they have to buy into it to derive the benefit, whereas I, in retrospect, wish I had had the opportunity to learn some of this when I was a trainee."

The so-called hidden curriculum, she says, continues to influence the thinking of young doctors. "They hear all the things about how they should be behave, but when they get to the hospital, they see doctors modelling a quite different form of behaviour. Or they encounter the cynicism of an overworked, under-slept resident. They observe that and think, 'That's what it's really like to be a doctor—not this stuff they teach in lectures.' And what they see in role models, in the end, is probably far more important than what they are taught in the classroom."

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