Giles Maskell: And that’s an order!

“I’ve just ordered a scan.” “Re-quested. You’ve just requested a scan.” This exchange between junior doctor and radiologist takes place countless times every day in hospitals across the UK. It’s generally accompanied by a half-smile of pitying incomprehension on the part of the junior doctor and a sigh of frustration from the radiologist.  

Leaving aside for a moment the point of language, the problem is that we are coming into this conversation with widely different expectations, neatly illustrated by a conversation I had with a junior doctor last year—“I’m trying to organise an MRI scan”, she said. “Oh yes,” I replied, “what’s the problem?” “Well the problem,” she said, “is that I’ve been told I’ve got to talk to you about it.” 

From my perspective, I have a certain expertise in medical imaging which includes the ability to advise on the most appropriate test to help resolve a specific clinical query. I am also to some extent the custodian of a limited resource and I see it as part of my role to make sure that the highest priority is given to the patients with the most urgent clinical condition and those for whom an urgent MRI scan is most likely to make the greatest difference. 

From the point of view of the junior doctor, her role in this case is essentially administrative. Someone has decided that this patient should have an MRI scan. Her task is to get it done as quickly as possible. She is not here to discuss whether this is the right test for this patient and still less is she concerned with how many other patients are waiting for a similar examination and how pressing is their need. It’s no wonder our exchange is dysfunctional.

Instances of friction and unpleasantness resulting from these conversations between referrer and radiologist seem to have become more frequent in the last few years. While some of that is certainly due to the increased pressure on all parties—whether to meet targets, to move patients ever more swiftly through the system, or to cope with ever increasing demands on a finite imaging resource—there has been a fundamental change in the nature of what is being asked. No longer is the referrer prepared to go along with the pretence—however inappropriate that may always have been—that they are asking a favour of the radiologist. They are now demanding something to which they feel entitled—placing an order if you like. This perception is enhanced by the proliferation of pathways, guidelines, protocols, and scoring systems. If the patient has reached a certain point on the flow chart for their condition and the next box is labelled “get an MRI scan”, then why would anyone feel the need to ask nicely? Surely the radiologists are aware of the pathway (and of their implied obligation to comply)?

The issue of competing priorities is generally ignored by those responsible for preparing disease-specific guidelines. With a limited scanning resource, the prioritisation of any one group of patients, whether those with cancer, stroke, trauma, or heart disease, inevitably comes at the price of making the service a little bit worse for every other group.

Contrary to popular belief, radiologists are not taught in the course of their training to give other doctors a hard time. If we sometimes do, it is usually because we genuinely don’t believe that what you are asking for is in the patient’s best interests. 

We do understand your predicament. Our polite request is that you also understand ours.

Giles Maskell is a radiologist in Truro. He is past president of the Royal College of Radiologists.

Competing interests: None declared.