Editorial
Respect... and all the rest
El respeto... y todo lo demás
P. Rodríguez Carnero
Editor adjunto junior de Radiología. Servicio de Radiodiagnóstico, Hospital Universitario de La Princesa, Madrid, Spain
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Ramalho, R.C. Semelka, J. Cruz, T. Morais, M. Ramalho" "autores" => array:5 [ 0 => array:2 [ "nombre" => "J." "apellidos" => "Ramalho" ] 1 => array:2 [ "nombre" => "R.C." "apellidos" => "Semelka" ] 2 => array:2 [ "nombre" => "J." "apellidos" => "Cruz" ] 3 => array:2 [ "nombre" => "T." "apellidos" => "Morais" ] 4 => array:2 [ "nombre" => "M." "apellidos" => "Ramalho" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173510720301051?idApp=UINPBA00004N" "url" => "/21735107/0000006400000005/v1_202210130655/S2173510720301051/v1_202210130655/en/main.assets" ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "Respect... and all the rest" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "393" "paginaFinal" => "396" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "P. Rodríguez Carnero" "autores" => array:1 [ 0 => array:3 [ "nombre" => "P." "apellidos" => "Rodríguez Carnero" "email" => array:1 [ 0 => "pablorodriguezcarner@ucm.es" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Editor adjunto junior de Radiología. Servicio de Radiodiagnóstico, Hospital Universitario de La Princesa, Madrid, Spain" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "El respeto... y todo lo demás" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In 1965, César Pedrosa published an article entitled “The respect of others”,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> in which he exposed and accurately analysed some of the problems radiology was facing in Spain at that time. He spoke of the intrusiveness of other specialities, of the danger of the dispersion of technology outside radiodiagnostic services, of the importance of all radiological tests being interpreted by a radiologist and accompanied by a report, of the limited teaching of radiology in the medical degree, the poor training of our technical staff, the need for a strong SERAM [Sociedad Española de Radiología Médica (Spanish Society of Medical Radiology)] of all and for all, the limited visibility of radiologists with patients, and more. In short, the importance of earning the respect of other clinical colleagues so that they would stop considering radiologists as mere “photographers” and recognise our role as clinicians.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Today, many of the problems referred to in 1965 by Pedrosa have already been resolved, and our speciality is in relatively good health: radiology and radiologists are a key and generally recognised part of the patient’s diagnostic and therapeutic process.</p><p id="par0015" class="elsevierStylePara elsevierViewall">However, reading that article from almost 60 years ago is disturbing, as some of the issues raised continue to exist or have returned. Will the new generations of radiologists know how to preserve the achievements of our predecessors? Will we know how to resolve the problems that remain pending? The future of radiology looks bright… but will it also be bright for radiologists? Will we die of success?</p><p id="par0020" class="elsevierStylePara elsevierViewall">To maintain the respect earned, I believe that, more than ever, we should be clinical radiologists and continue to actively participate in the discussion and decision-making forums just as any other specialist, without any complexes and making our professional opinion heard. We need to be indispensable for our colleagues in other specialities, providing a useful, valued and crucial quality service.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> We are the specialists in medical imaging and responsible for the clinical-radiological correlation, the people who interpret the images in the clinical context of the patient, not people who describe images that others later correlate with the symptoms. Perhaps it is time to banish from our reports that hackneyed and meaningless catchphrase, “Recommend clinical correlation”.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">We need to continue to defend our role as the main decision makers in the choice and indication of the most appropriate radiology test for each case. We need to uphold our responsibility in the suitable programming and optimisation of our tests, particularly regarding the use of ionising radiation and contrast media.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> The request for a radiological examination is a referral to a radiology service, the presenting of a clinical problem it is our job to propose a response to with the most appropriate imaging test.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Can anyone imagine a general surgeon receiving a request for “laparoscopic cholecystectomy” for a patient and not taking the time to assess the patient, the indication for surgery or the surgical approach themselves? Then, if the surgeon reasonably did not consider the cholecystectomy appropriate or decided to do it open instead of laparoscopically, can anyone picture the requesting doctor flying into a rage because the surgeon did not perform the surgery they had requested? It is obviously a crude analogy, but we must never forget that as medical specialists we are ultimately responsible for carrying out radiology tests according to the law.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">To preserve the respect of others and be seen as guarantors of the correct use of medical imaging, we must maintain an optimal relationship with our medical colleagues; frank and fluent collaboration, involving mutual recognition, peer to peer.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> This includes reasonably arguing when we believe that a certain test will not be helpful for a particular patient, offering other solutions, or setting out the relevance of doing another test which may be more useful. Let’s empathise with the medical colleague who requests our collaboration, let's help them answer the question they ask us, let's be an active part of the diagnosis and treatment of our patients.</p><p id="par0035" class="elsevierStylePara elsevierViewall">We must continue to protect our radiology services as benchmarks for medical imaging and hubs for radiological technology. The dispersal of radiological equipment outside our departments is a throwback to 1965. It entails additional costs for the whole of Healthcare, loss of the overall vision that we provide as specialists, and loss of the filter and supervision or surveillance radiologists have to exercise as experts in the standardisation of radiological examinations.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">I think it essential that we always keep in mind that behind all our work, behind these images, there are patients, human beings, who are the main beneficiaries of our commitment and who we must be capable of empathising with from the distance of our screens if we are to give our best.</p><p id="par0045" class="elsevierStylePara elsevierViewall">As far as the visibility of radiologists towards patients and the general public is concerned, SERAM has been working for some time on various initiatives and dissemination campaigns, and promoting its channels and profiles on social networks. In a world like ours, added to good work, good publicity is a must. We need to keep doing a good job in selling ourselves.</p><p id="par0050" class="elsevierStylePara elsevierViewall">We have to stand up for our duty to supervise the performing of radiology tests, or actually doing them when that is the case, as in ultrasound and interventionism. We are the medical professionals best trained for these tasks. It is said that ultrasound “is lost” and that “any doctor performs ultrasound”. Perhaps this is already partly the case and we should learn to be pragmatic and adapt and work in this new situation. We should not, however, simply dismiss ultrasound, delegate it or abandon it. We should continue to consider it like any other provision of our portfolio of services and keep performing ultrasound as radiologists to ensure the highest possible quality. And the “plain” X-ray? I get the feeling that successive generations of radiologists have less and less training in these techniques, creating a vicious circle of “ignorance-disinterest-discredit-desertion-ignorance”. In addition, little by little, we have neglected to ensure that the staff in our departments have the right skill mix to be able to report all the tests that we generate. The main consequence of this is that a significant percentage of plain X-rays performed in many departments around the country are not supervised or reported by a radiologist, despite being simply another radiological examination, no less important than a CT coronary angiogram or MR enterography. This not only means a loss of quality of care, but is also directly in violation of our obligations, since the law clearly establishes that all radiological examinations must be accompanied by a report by the radiologist.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> We cannot afford to take the path of giving up on “plain” X-rays.</p><p id="par0055" class="elsevierStylePara elsevierViewall">To give the best of ourselves we have to constantly be moving forward, which we can only achieve through a continuous process of evaluation, improvement and re-evaluation. As radiologists, hand in hand with the other healthcare professionals in our services, we have to get fully involved and take responsibility for the overall management and quality control of our activities.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> If we avoid this task we will lose control over our own work.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Little can be added to the debate about the situation of our technical staff; they are essential healthcare professionals who, in general, receive training with much room for improvement, and who are also at a comparative disadvantage compared to their European colleagues. The solution could be to definitively convert their training into a university degree.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Our changing society will require new healthcare professionals, who address the new situations and challenges that are emerging, such as the progressive ageing of the population, the imbalance of resources in the “emptied Spain”, our patients increasingly well informed, emancipated and demanding, the full professional representation of women (already a majority in Spanish radiology for years, although still a minority in decision-making positions), global migratory phenomena, and our evolving towards a more diverse society in all senses of the word. This has also been happening in radiology, as for decades we have had a higher percentage of residents and radiologists from overseas or at least of foreign origin working in our society, although still not translating into proportional representation in leadership positions.</p><p id="par0070" class="elsevierStylePara elsevierViewall">To maintain the respect we have earned, we must ensure that our future generations are adequately prepared. I do not want to enter the field of undergraduate university education or continuing education, which would give rise to many more reflections. Perhaps the most important part is postgraduate training: the residency, which is the part in which the largest number of radiologists participate.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Training through the “residency” format is a fantastic method, as it offers the best way to learn: working and practising as a professional alongside experts. I know of no other training model that is as good and as equitable. Through a reasonably neutral and objective selection process, also open to colleagues from the European Union and from outside the EU, a doctor voluntarily chooses a position to learn a speciality (equivalent to a master’s degree), while earning a salary working and practising their future work as a specialist. As it is an eminently practical apprenticeship with hardly any theoretical and passive “master” lessons for the trainee, it allows the focus to be placed on the main person responsible for their training: the resident themselves. That’s where we need to get involved.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Technical or medical radiological knowledge today is almost ubiquitous and with relative ease of access in countless good books, scientific articles, webinars, internet portals, etc. In our hospitals there is usually a good variety of cases and good clinical medicine for the basic training of future radiologists, and the doctors who reach the residency stage generally have sufficient intellectual capacities to tackle their postgraduate training. The key that I believe will make the difference is to train our future specialists in professional values, such as responsibility, autonomy, critical and analytical skills, communication, teamwork, empathy and leadership<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a>; creating radiologists of the future who are not only capable of absorbing and applying knowledge, but also able to produce more, who evaluate, reason and discern, who solve problems by themselves and as a team.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Learning about responsibility is one of the key points. The gradual adoption of competencies with decreasing supervision is another of the successes of the residency; we must not forget that the residents are doctors and adults, with a salary and care workload: it is just as bad to leave an R1 absolutely alone as it is to supervise absolutely all the work of an R4. It is just as bad to use residents as cheap labour to cover structural deficiencies in a workforce as to consider them passive subjects without any type of task or responsibility.</p><p id="par0090" class="elsevierStylePara elsevierViewall">We radiologists have to be scientists, and keep alive the investigative, restless and critical spirit; not stop asking ourselves questions about how to improve our practice. To continue to be respected as medical imaging professionals, there is no question that we also need to lead research in our field, including cutting-edge areas such as artificial intelligence, participating in cross-cutting multidisciplinary groups which go beyond medicine and include professionals from other areas, such as engineering, computer science, mathematics and physics. Otherwise others will take our place.</p><p id="par0095" class="elsevierStylePara elsevierViewall">For all this we need time. It is essential that our administrators and managers understand that our job is not just to sit in a chair and read images and issue descriptive reports, or puncture and insert catheters in a theatre. As I mentioned above, our work is also in the clinical correlation, the planning of our interventions, the management of our services, the hospital committees and commissions, the clinical and teaching sessions, the interaction with our colleagues and resolving problems that arise as we go and, of course, in the time invested in teaching and research. Always quality before quantity.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">To achieve that, we also need resources. We cannot continue with one of the oldest fleets of technology in the European Union.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> We need adequate human resources, with a sufficiently large workforce capable of absorbing the huge, and growing, demand for radiological examinations. Some 33.7% of medical contracts in public health and 20.6% in private are temporary<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>; these high rates of job instability and precariousness, which particularly affect the younger generations, are unacceptable, and make it very difficult to design lasting and long-term projects, while also generating helplessness and anxiety in the healthcare professionals.</p><p id="par0105" class="elsevierStylePara elsevierViewall">To protect our interests as a speciality, it is essential to have a strong SERAM, which is created and nurtured from the base up, of which we are all members, and which looks after its base. A very open SERAM that everyone feels they belong to, in which we collaborate to the best of our ability (if not all radiologists, at least as many as possible).</p><p id="par0110" class="elsevierStylePara elsevierViewall">To continue this great adventure that is bigger than us all, it is essential to ensure the relief: leaders are necessary, but it is no use having only a few powerful runners, the important thing is to ensure a good reserve pool of young runners to guarantee the continuity of what is an exciting community project, linked to a solid, long-term strategy. In the words of the Cuban band, La Vieja Trova Santiaguera, <span class="elsevierStyleItalic">“In the end the works remain and the people leave. Others who come will continue them…”</span> No one is indispensable, but at the same time we all are.</p><p id="par0115" class="elsevierStylePara elsevierViewall">In summary, the new generations face the challenge of maintaining the progress already made and adapting to the changes that are happening now and will happen in the future. It is impossible to predict the future, but the best way to prevent changes from taking us by surprise is to be the ones leading them.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> I believe that we can only maintain the respect of others by cultivating and defending an active role for radiologists, guarantors of the quality of medical imaging. If we passively hide away in our dark dens, with a false sense of calm and ease, the world will continue to move forward and we risk fading out of existence.</p><p id="par0120" class="elsevierStylePara elsevierViewall">In the end, we find ourselves in many respects just as in 1965. Why? Because ultimately this is not about isolated impulses, it is about constant, continuous and routine day-to-day work. Oh, and thank you very much Dr Pedrosa.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "El respeto de los demás (hacia una radiología mejor)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "CS Pedrosa" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Radiología" "fecha" => "1965" "paginaInicial" => "327" "paginaFinal" => "335" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The spider model for clinical involvement in radiology" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "JA Reekers" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s13244-014-0326-4" "Revista" => array:6 [ "tituloSerie" => "Insights Imaging" "fecha" => "2014" "volumen" => "5" "paginaInicial" => "403" "paginaFinal" => "405" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24844882" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The vanishing radiologist-an unseen danger, and a danger of being unseen" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "AP Brady" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00330-021-07723-1" "Revista" => array:6 [ "tituloSerie" => "Eur Radiol" "fecha" => "2021" "volumen" => "31" "paginaInicial" => "5998" "paginaFinal" => "6000" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/33569618" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Recommend clinical correlation: a common but meaningless phrase in radiology reporting" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "SJ Kuzminski" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jacr.2015.03.016" "Revista" => array:5 [ "tituloSerie" => "J Am Coll Radiol" "fecha" => "2015" "volumen" => "12" "paginaInicial" => "775" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26092591" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Radiologists: physicians or expert image interpreters?" 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