RSNA 2019: The Literary Radiologist: Writing Our Patients, Our Experiences, Our History.
Wednesday 12/4/2019 8:30-10:00 AM | RC524 | Room: S504AB
AMA PRA Category 1 Credits™: 1.50 | ARRT Category A+ Credit: 1.75
Moderator Bruce J. Hillman, MD Wake Forest, NC (Moderator)
Disclosure: Royalties, Oxford University Press Royalties, Lyons Press Royalties, University Press of New England
1) Overcome barriers that have made you hesitant to write about yourself, your experiences with patients, and what it means to you to be a radiologist.
2) Express and receive constructive criticism about your own and others' creative writing as a means to improving your writing skills.
3) Read your writing aloud and in public to gain confidence that what you write is interesting to others.
4) Make an effort to publish your writing.
The presenters wish to involve the audience. For those interested in actively participating, please consider reading some of the writings by the presenters and other radiologists below.
Better yet, email a short piece of creative writing of your own to firstname.lastname@example.org.
Dr. Hillman will vet contributions for civility (no ad hominems, gratuitous profanity, etc.) then post your contribution with the others.
Sample writing for discussion:
SEE ONE, DO ONE, WRITE ONE: The Standoff
Stephen D. Brown, MD
Brown SD. The Standoff. J Am Coll Radiol. 2017 Apr;14(4):547-548. doi: 10.1016/j.jacr.2016.12.022. Epub 2017 Mar 6. PubMed PMID: 28274692.
For 16 years, I have kept taped to my desk a passage taken from a book written by an inspiring young woman with cystic fibrosis. Published posthumously, the book details the complex interplay of her medical, social, and emotional life . In one chapter, she writes: “Saw good ol’ dr. brown (he’s done all of my interventional radiology stuff) in the cafeteria and he stopped by to hear the latest news. I like docs that keep up even when they aren’t currently involved.”
I had met the patient 2 years previously, in 2001, early in my career as a pediatric interventional radiologist. One evening, she developed severe hemoptysis requiring emergent bronchial artery embolization. Her mother, who as a parent probably had as much experience in hospitals as I had as a physician, insisted on remaining in the interventional suite during the procedure. This was an unusual and unnerving request. We sometimes invited parents in for simple procedures, but never for complex procedures that required sedation in fragile patients.
On one level, I believed that the patient’s interests would not be well served by granting her mother’s request. Her presence in the room would add unfair stress to the team and an unknown variable to an already unstable clinical situation. I could not predict how events might unfold if an adverse event occurred. These seemed reasonable objections. But, there was another level as well. Even though I had excellent training, I had done few embolizations on my own, and I remained insecure about my skills. I was afraid that she would see my inexperience, or worse, incompetence. Apprehensive and stressed, I, like she, was anxious to exert control.
It was a classic difficult conversation. How much of my rationale should I explain? How could I discuss my concerns without offending her, or worse, frightening her more than she might already have been?
Now, 16 years later, I might counsel my own trainees to sit with the mother to talk gently about her concerns and to listen empathetically first before expressing their own concerns. I might urge my trainees to validate the mother’s disquiet and to admit to similar feelings if their own loved ones were in comparable circumstances. We might explore together whether to acknowledge openly to her the stress already in the room, the need to maximize variables that were controllable, and the desire to not introduce unknowns into an already tenuous circumstance. Ultimately, I might advise my trainees to create a comfortable space where the mother could voice her concerns freely, and where they could hopefully establish a mutual respect, rapport, and trust. I might even later create a vignette around this conversation that my trainees could re-enact with actors in a controlled simulated environment with opportunities for constructive feedback from actors, mentors, and peers.
However, at the time of this interaction, no such opportunities existed for training in communication skills. I found myself in an exceptionally difficult conversation with nothing but observation and previous personal experience from which to prepare. After a tense exchange, I declined her request, and she accepted the decision.
The procedure went well, as it should have given the meticulous technical training my team and I had (despite my insecurity). What about the communication? Had I done that well? Certainly my training for speaking to the patient and parent stood in stark comparison to the training I had for performing the procedure itself.
The situation transported me back 10 years previously, when, as a junior neurosurgery resident in California, I found myself leading a team meeting with a family whose son had been neurologically devastated after a motor vehicle accident. The time had come to consider withdrawing mechanical ventilation. I was the only physician in the room. The other participants included the patient’s nurse, a priest, and a Spanish translator. The meeting accomplished its objective: the family agreed to discontinue life support. Afterward, I had a burning need to know how I had done. What could I have said better or differently? I asked the priest if I had done a good job. “Yeah, fine,” he answered. He walked quickly away, leaving me uneasy. After 25 years, I still recall that meeting and wonder if the family remembers that conversation. My enduring sense is that they deserved better, and so did I.
When formal opportunities to learn relational proficiencies are unavailable and communication skills are not taught, learning still occurs, sometimes actively and sometimes passively. The processing is commonly subconscious, but the lessons penetrate nonetheless. Past conversations that we witness between physicians and patients during our early training experiences lay dormant until they surface in the present.
Once, as a medical student back in 1988, I passed a patient’s room and overheard a neurology resident yelling to an elderly stroke patient: “YOU’VE GOT BLOOD IN YOUR BRAIN.” “What a buffoon,” I thought to myself as I walked by. “What an insensitive dork!” Three years later, as a neurosurgery resident, I heard myself repeating these same words when called to the emergency room one night to evaluate a man who had suffered a pontine hemorrhage. His wife and I stood across from him as he lay unconscious and intubated on the gurney. She was noticeably pregnant. “He’s got blood in his brain,” I explained. It was all I could think of.
About 2 years later, I walked into a café where a woman and small child were seated. She recognized me and came over. It was the wife of the patient with the pontine hemorrhage. He had survived after a prolonged hospitalization. She told me that my words at that first encounter were her most vivid memory of the entire experience: “He’s got blood in his brain.” Such is the power of informal relational learning in medicine that a conversation overheard outside a hospital room in Philadelphia in 1988 would hold such enduring impact for a completely unrelated individual in Palo Alto in 1993. Once again, I was struck with an overwhelming sense: the patient’s wife deserved better, and so did I.
By the time of that encounter in the café, I had left neurosurgery with plans to begin a diagnostic radiology residency in Massachusetts. The specialties were as different as the Pacific and Atlantic Oceans, with one notable exception: The only opportunities to learn about communicating with patients were random observation and real-time practice. As I rotated through ultrasound, fluoroscopy, interventional radiology, pediatric radiology, and obstetric imaging, I realized that such opportunities were abundant and that the exchanges could be intense: informing a woman of a miscarriage, performing a palliative paracentesis on a woman with advanced ovarian cancer, obtaining consent from a patient for a high-risk biopsy, apologizing to another for having to repeat a botched study, explaining to the parent of a child with cerebral palsy that I had broken his child’s severely demineralized leg while maneuvering him during fluoroscopy.
Over time, it has been gratifying to see emerging awareness of the need for formal communication and relational skills training in radiology. Overall, however, such curricula remain scarce. Even as CT and MRI revolutionized medicine, speech recognition software became commonplace, and teleradiology broke traditional market barriers, we still tend to learn communication skills the old-fashioned way: “See one, do one.”
My skills gradually improved as I observed others, gained clinical experience, and grew more confident. But there was much room to grow, as I learned during the evening standoff with an apprehensive parent who wished to be present for her child’s procedure. My only gauge of success regarding that conversation was that I managed it without burning bridges that grew more important over time, because this patient required multiple additional procedures. Indeed, over the next 2 years, I came to know this delightful young woman and her parents well, to the point of periodically visiting her in the hospital just to say hello and catch up. Certainly, the door to these small interactions would not have been open if the procedures had not gone reasonably well. However, I also believe that door would not have been open had the communication failed.
The relationship with this patient with cystic fibrosis and her family took me into a world that enriched me indelibly. I met a circle of family and care providers who showed me the dignity achievable in sickness and in death. I learned how my small gestures of caring as a radiologist could be deeply appreciated. Just as acquiring a new language introduces one to new, previously inaccessible experiences and people, so too does the ability to communicate well with patients, even in radiology. It is a marvel, really, that allows us to join meaningfully with patients in their journey and to connect with them in mutually enriching ways.
As the old learning paradigm hopefully yields to newer models for teaching relational skills, radiologists will find more avenues to such relationships. The patients deserve this, and so ultimately do we.
REFERENCE 1. Rothenberg L. Breathing for a living: a memoir. New York, NY: Hyperion; 2003. The author has no conflicts of interest related to the material discussed in this article.
Stephen D. Brown, MD: Department of Radiology, Boston Children’s Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115; e-mail: Stephen.email@example.com. 548 Journal of the American College of Radiology Volume 14 n Number 4 n April 2017
ª 2017 Published by Elsevier Inc. on behalf of American College of Radiology 1546-1440/17/$36.00 n http://dx.doi.org/10.1016/j.jacr.2016.12.022 547
Chapter 16: Frozen
Unpublished Excerpt: Unpublished memoir tentatively titled "The Hot Seat" by David Levin
There was an old saying among Air Force pilots back then that flying jet fighters, even in peacetime, was 99% boredom and 1 % sheer terror. I don’t remember being bored too often but I sure do remember the 1%. One of those episodes occurs in the fall of 1957. I’ve finished F-86D training and am in the 514th Fighter-Interceptor Squadron at RAF Station Manston in the UK. As a new pilot in the squadron, I’m required to do a navigation check flight to demonstrate that I know how to file a flight plan, navigate an extended course, and get myself back to the point of origin. The whole thing is pretty silly. Do they really think that after 18 months of training and several cross-country flights, I can’t file a flight plan and follow it? But the squadron has its rules and I guess I have to abide by them.
On the assigned day, I file a triangular flight plan from Manston in southeastern England to a radio navigation beacon up north in the midlands, then to another beacon in southwestern England, then back to the beacon at Manston. I take off in my F-86D, accompanied by another one piloted by First Lieutenant Bob Kirk. Kirk and I are the same rank but he’s a more senior pilot in the squadron who is assigned to check me out.
It’s a clear day and there isn’t much to do except fly from beacon to beacon and watch the scenery—it’s one of those few missions that’s actually uneventful. Aside from turning the knob on the frequency selector to pick up the next beacon and glancing occasionally at the direction finder that points toward it, I sit there listening to the low, steady, familiar hum of my engine. I might be lulled to sleep by the cockpit calmness except at the back of my mind, I know I have to keep alert for any tremor, thump, rumble, or vibration that could suddenly signal engine trouble.
Manston is on a peninsula jutting out into the North Sea about 50 miles due east of London, and as we head back in toward the base from the southwest at 45,000 feet, I have a clear view of the North Sea ahead and the French coastline off to the right beyond the English Channel. The scenery is nice and I’m probably daydreaming about things other than flying. Kirk is flying loose formation off my right wing. Pretty soon my radio direction finder needle swings from pointing straight up to pointing straight down, signaling that we’re passing over the North Foreland radio beacon right near Manston. That means it’s time to begin our descent to get into the traffic pattern. Daydreaming over, back to business.
I start to push the stick over to the left for a descending turn, and … it won’t move. The damned thing is frozen! I push my left rudder pedal to see if I can turn that way. It too is frozen. Thereupon ensue perhaps the worst 15 seconds of my life. I’m getting low on fuel and heading out over about 200 miles of very cold North Sea before the next landfall, with my controls frozen. Should I eject right then and there while I’m still over land? But I’m going so fast and at such high altitude that ejecting would probably mean death. In a state of near panic, I try to figure out what’s wrong and what I should do.
The flight controls are operated hydraulically and the hydraulic pressure gauge shows normal pressure. So it’s not a hydraulic system failure. Down below I see the shoreline starting to pass beneath me; in a few seconds I’ll be out over water and the bailout option will be even more dangerous.
Then suddenly the realization hits me. About 20 minutes earlier, since I was flying a straight and level course with nothing much to do, I had switched on the autopilot. We almost never use autopilot during normal training missions, so I’m not used to using it, and forgot that I’d turned it on. That froze the controls. Simply flicking the switch to the off position solves the problem. A huge wave of relief washes over me.
The rest of the descent and landing are happily uneventful. I’m giddy with the realization that I’m not going to die that day after all. Later, on the ground, Kirk asks me why my wings had jerked up and down very slightly several times just after we had passed over the North Foreland beacon. It had happened because in my desperate efforts to move the frozen stick, I’d been able to nudge it about a quarter of an inch in each direction, which was just enough to deflect the ailerons a bit and thereby move the wings up and down very slightly. I explain it to him and we both have a good laugh. But it wasn’t so funny for those 15 seconds.
There’s of course a fine line between “near panic” and “panic.” The reason I feel I was in a state of near panic rather than full-on panic is because if I’d been in full-on panic, I’d probably not have remembered about that autopilot switch. Thank God I at least had enough presence of mind left to think my way out of that wacky predicament. Otherwise my bones might be out there somewhere at the bottom of the North Sea.
Chapter 1: My Nightmare Begins
(Unpublished first Chapter of a memoir tentatively titled, “Shaky” by Bruce J. Hillman, MD)
“Stop it. That tickles…and not in a good way.” Jane rolled out of my embrace and rubbed her left shoulder.
“I’m sorry,” I said, knowing that my apology sounded perfunctory. “Honestly, I didn’t realize that I was doing any tickling.”
Rolling to my side of our bed, I progressively unhinged my knees, hips, and shoulders, stretching upward on extended toes all of my five feet-eleven inches, from the balls of my feet to the crown of my shaved head. I stepped across to the cabinetry lining the loft and gazed through leafless branches to the snow-covered Blue Ridge Mountains.
Lifting my left hand, I made a show of studying its appearance. Absent-mindedly, without really thinking about it, I raced through what I had been taught about physical examination in medical school. Palor, rubor, dolor, tumor… Paleness, redness, pain, swelling…all absent. What gave me pause was what I thought I felt when I bunched my fingers together…a sense that the tips of my fingers were rubbing against one another.
My brain cramped trying to recall what I had learned about tremors in medical school. It was hopeless. Having become a radiologist, I had long ago swept this knowledge into the cerebral dustbin of unused, and, therefore useless, information. The only thing that came to mind was Parkinson’s disease. A faint wave of nausea swept across my belly. But no, that couldn’t be it. I didn’t have time for a relentlessly progressive neurological condition that could interfere with nearly every bodily function and leave me a demented shell of a human being. I’m a physician, I thought. I don’t get diseases. I help cure them.
Later that day, I consulted the Worldwide Web. Aside from porn, there are probably more digital bits on the Internet devoted to health care than any other topic. Unfortunately, the Web is strictly caveat emptor. Even for a physician, it can be very difficult to distinguish valid information from the vast array of unsubstantiated assertions, homeopathic recommendations, bubbe meises, and outright frauds that haunt health care information on the Worldwide Web. An individual with some but not enough knowledge, made anxious by the fear of what he might uncover about himself, is at even greater risk than most. I was putty in the Web’s cold, digital hands. Essential tremor…drug interactions…tremor of psychogenic origin… No, that’s too simple…Brain tumor…only months to live…Parkinson’s disease. That’s it! I am well on my way to raving dementia.
I calmed myself. Couldn’t my tremor be a manifestation of excess stress? I had allowed myself to become overwhelmed at work. As chair of the Department of Radiology at the University of Virginia, I was responsible for helping develop the academic careers and ensure the livelihoods of more than fifty faculty physicians, forty physicians-in-training, and hundreds of nurses, technologists, and administrative personnel. My stress was no less at home, where I nightly engaged in the bitter dialogue of an unhappy marriage. Who wouldn’t acquire a tic or two? I ignored the tremor, even as it progressively grew more severe.
Ultimately, the energy I expended on my anxieties left too little in reserve to support my denial of the fact that something was wrong. Even so, I might well have continued on with this behavior except for my serendipitously running into Dr. G. Frederick Wooten cruising a back hallway of my department. Better known as “Fred,” Wooton was a short, well-built man in his sixties, with a full head of black hair. He was completing a long stint as chair of the University’s neurology department. He was a nationally renowned specialist in movement disorders, of which Parkinson’s disease is the most common and most widely known.
Fred hadn’t seemed to be in any particular hurry. Rather, he appeared to welcome the unexpected opportunity to speak off-line with a fellow fly fisherman and department chair. It seemed to me the right time to test divesting the armor of denial in which I had clad myself. On a whim, I showed him the movement that troubled the fingers of my left hand. He watched silently for a long moment, during which the minuscule trembling grew in my view to outsized proportions.
Fred asked me a few questions. Was the tremor intermittent or constant? What helped make it better? Did it worsen in cold temperatures? Did it become more pronounced if I were anxious or excited? Beyond that, Fred didn’t say much…just that I should make an appointment to meet with him in his clinic. The hard clap he delivered to my shoulder before heading off seemed to me more a diagnostic test than a friendly gesture of farewell.
That night, I first dreamt what I now refer to as “my dream.” Repeated on a number of occasions since, unwelcome images creep into mindfulness as my consciousness crosses the blurred border between wakefulness and sleep. The images come slowly at first, then cinematically, roiling like clouds before a storm. I see myself plummeting downward from a great height towards rugged, uneven terrain. The descent pares from the periphery of my vision distant granite-strewn mountains, the mercurial glint of a river snaking through bare-limbed forests, until my fall abruptly comes to rest. I hover above a glass terrarium built to human scale. My eyes penetrate its transparency, magnifying, focusing, and cropping the limits of my vision until the reclining figures of a man and a woman fill the frame. The pair sprawl on tussled sheets. Intertwined body parts paint an abstraction of sharply drawn angles, filtered and processed by subconscious memory until every line is elevated into sharp relief. I record the curve of a shoulder, a well-shaped arm. My eyes scan past the man’s elbow and wrist to linger on the first three digits of his left hand. A leitmotif, familiar in sleep but defying waking recognition, signals something momentous is about to be revealed. The music crests. A faint, rhythmic trembling alternately slides into focus and blurs the man’s fingertips.
Sleep has returned me to these images many times. They come unpredictably. Despite their familiarity, I am perpetually surprised. As with a musical rondo, the possibilities for variation are infinite. Despite my best efforts, I cannot identify the willowy, long-limbed woman who haunts my dream. Although there are similarities, the woman is not Jane. The man is undeniably I.